Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lumbago, Schizoaffective personality disorder, Anxiety, Depression
Treatment: Increase in consumer directed personal care assistance hours at 20 hours per week
The insurer denied coverage for an increase in consumer directed personal care assistance hours at 20 hours per week. 
The denial is upheld. 

This is a female patient with a medical history of lumbago, schizoaffective personality disorder, anxiety and depression. A Uniform Assessment System (UAS) report was done. It is noted that the patient's psychiatric symptoms are well-controlled with weekly psychiatric therapy. The patient needs extensive assistance with meal preparation and ordinary housework. The patient needs limited assistance with bathing. The patient is independent with personal hygiene, dressing her upper and lower body, locomotion, toilet transfer, toilet use, bed mobility and eating. The patient walks with an assistive device. The patient can prepare light meals. The patient reported that she is suffering from lower back pain which limits her ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient has problems with standing/walking for long periods of time. An increase in consumer directed personal care assistance services from 10 to 20 hours per week is being requested.

The insurer denied coverage for the request to increase consumer directed personal care assistance hours from 10 to 20 hours per week. In their Final Adverse Determination letter, the insurer states the consumer directed personal assistance provided under the last authorization or reauthorization was still sufficient to meet the patient's needs. The patient reported having some health issues, but the changes in her medical condition were not major. The reported changes also did not impact her current personal care needs. The letter states that the insurer will continue to keep the services the same at 10 hours of consumer directed personal care assistance per week. The insurer concluded that these hours were enough to help the patient with her ADLs, such as bathing, dressing, toileting and housekeeping related services.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 7/6/16 

(a) 	Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

The available documentation does not indicate in what way the patient's ability to do ADLs has deteriorated since the UAS was done. At that time, the patient was independent for ADLs and could do some IADLs with set-up. The patient has chronic medical problems that appear to have been taken into account. The documentation submitted for this review does not clarify what deterioration has occurred in her ability to do ADLs that would warrant an increase in hours to 20 per week. Thus, the basis for increasing hours from 10 to 20 per week is not established. The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the requested increase in consumer directed personal care assistance hours at 20 hours per week should be upheld. The medical necessity is not substantiated.