Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation, anxiety, pre-diabetes, hypertension, urge incontinence, asthma, morbid obesity, gastroesophageal reflux disease (GERD)
Treatment: Consumer Directed Personal Care Assistance Services, 4 Hours per Day, 5 Days per Week (Monday through Friday) for a Total of 20 Hours per Week

The insurer denied Consumer Directed Personal Care Assistance Services, 4 Hours per Day, 5 Days per Week (Monday through Friday) for a Total of 20 Hours per Week.
The denial is upheld.

The patient is an adult female with a history of general debility and awaiting foot surgery. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from nine hours per week based on Uniform Assessment System (UAS) of 5 months ago to 20 hours per week. The health plan denied the request because the patient's request for an increase is not medically necessary, and the New York state regulations do not require personal care assistance services for safety supervision alone, as the patient is not cognitively dysfunctional. The current nine hours per week were deemed sufficient to meet her current needs. The additional hours requested are because the patient is having an upcoming foot surgery (past date). A review of the records showed that the patient has multiple chronic medical conditions including atrial fibrillation, anxiety, pre-diabetes, hypertension, urge incontinence, asthma, morbid obesity, and gastroesophageal reflux disease (GERD). Uniform Assessment System-New York (UAS-NY) evaluation of earlier this month showed that the patient is independent cognitively for bed mobility and eating; requires supervision/setup for managing finances and phone use; requires limited assistance for managing medications, personal hygiene, upper body dressing, walking, locomotion, toilet use; requires extensive assistance for stairs, bathing, lower body dressing; and requires maximum assistance for meal preparation, housework, shopping. The patient's family support is good, and she lives with her daughter and two grandchildren in a two-bedroom apartment on the second floor in a building with no elevator access.

The requested health service is not medically necessary.

The requested increase for Personal Care Assistance through Home Health Care (Level 2) from nine hours per week based on Uniform Assessment System (UAS) of 5 months ago to 20 hours per week is not medically necessary because, based on the most recent Uniform Assessment System of earlier this month, the patient is independent cognitively for bed mobility and eating; requires supervision/setup for managing finances and phone use; requires limited assistance for managing medications, personal hygiene, upper body dressing, walking, locomotion, toilet use; requires extensive assistance for stairs, bathing, lower body dressing; and requires maximum assistance for meal preparation, housework, shopping. There is no tangible difference in the Uniform Assessment System of both days to warrant an increase in needs. The patient's family support is good and the patient lives with her daughter and two grandchildren in a two-bedroom apartment on the second floor in a building with no elevator access. The reason for denial by the health plan as stated in the clinical information above, does align with the patient's disability features as stated in the Uniform Assessment System of earlier this month as stated above and is not that different from the previous Uniform Assessment System of 5 months ago. Therefore, the requested 20 hours per week based on Uniform Assessment System of earlier this month should not be approved. The requested health service is not medically necessary.