Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Home Health Care. 
The insurer denied increase in personal care assistance to 56 hours per week. 
The health plan's determination is upheld.

The patient is a female with a past medical history significant for ambulatory dysfunction, varicose veins with intermittent pain, osteoarthritis, chronic heart and lung disease, hypothyroidism, chronic tremor, and osteoporosis. This review is for increase in personal care assistance services to 56 hours a week. The patient is currently approved for 35 hours a week, 5 hours per day 7 days a week. Increase in services to 56 hours per week were denied by the health plan based on lack of medical necessity. Services were denied based upon medical necessity. At issue is the medical necessity of the requested increase in personal care assistance services.

The increase in personal care assistance services to 56 hours per week is not medically necessary for this patient.
Services were denied by the patient's insurance stating this service is not medically necessary. Per the denial it is indicated - You stated that you needed an additional 12 hours more due to having multiple health conditions. You state that you needed more services to assist with your daily activities. You are currently approved for 35 hours a week. Based upon reviewing her most current assessment we will continue to prove recurrent hours which is enough to support your current activities of daily living: Bathing, dressing lower body, personal hygiene, dressing upper body, walking, locomotion, toilet transfer and toilet use. The physician's statement, recommended increase in services to 12 hours per day.
Uniform Assessment System (UAS) State of York was noted. The tasking tool noted a total of 25 hours a week, most of the services include Instrumental activities of daily living (IADLs). The patient does need limited assistance uncertain activities of daily living (ADLs). The patient currently lives alone in a one-bedroom apartment. The patient was observed ambulating and has unsteady gait but is able to ambulate with a quad cane indoors and outdoors.
The prior UAS State of York was reviewed. The patient has multiple medical problems with generalized physical decline including arthritic complaints along with increasing complaints and easy fatigability. She currently lives alone in a one-bedroom apartment. She has personal care assistance (PCA) hours of 35 hours a week, 5 hours a day 7 days a week. The majority of her PCA hours were used to support IADLs. The patient does have the ability to ambulate in her apartment independently with an assistive device. She needs limited assistance for most ADLs. There was a noted decrease in her functional abilities between assessments. Assessments allow for an additional 10 hours a week of services beyond what is noted to be medically necessary.  There was no specific event or other medical episode noted between the last nursing assessment and the current review. There were also no other medical reasons noted why the services being provided require additional hours and cannot be provided during the amount of time approved. 
In summary, the documentation does not support the medical necessity for increase in service hours.