Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Home Health Care. 
The insurer denied home care/personal care HHC - Level 2 personal care services per 15 minutes increase to 84 hours per week from 35 hours. 

The patient is a female with a past medical history significant for rheumatoid arthritis, hypertension, gastroesophageal reflux disease, congestive heart failure with no loss of motor function, and seasonal allergies. The subject under review is the medical necessity for increasing personal care services from 35 hours per week, which the patient currently receives, to 84 hours to week. Services were denied by the health plan on the basis that the patient's personal care needs are 35 hours a week.

The requested health service is not medically necessary for this patient.
The denial by the health plan indicates that the current hours are 35 weekly, and that there is no medical necessity to increase the hours to 84 hours weekly. Department of Health's Uniform Assessment System (UAS) tool demonstrated no changes most of the patient's physical functioning since her prior assessment.
Further the denial stated that evaluation showed no changes with your abilities to perform physical function such as bed mobility (moving around the bed), bathing, personal hygiene (cleaning yourself), dressing upper and lower body, walking, eating, meal preparation, ordinary housework and medication management. Her memory is okay. There is a report of bladder incontinence but no bowel incontinence. The member was reassessed, and authorized hours were adjusted accordingly. The personal care hours are currently authorized in the amount, duration scope necessary to meet the member's personal needs. Hours beyond those currently authorized would be for safety monitoring, which is not a covered benefit of the personal care services program.
UAS was reviewed. The member ambulates with a roller walker inside. Member requires assistance with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) due to physical limitation. The member had 2 falls within a 2 month period outdoors, fall was noted to be secondary to dizziness. Tasking tool noted a total of 35 hours a week. This was an increase in services noted last time which noted 16 hours a week of services. With differences in time mainly related to locomotion dressing lower extremity and toileting.
The previous UAS was reviewed.
There was no noted physician statement or progress note provided for description of the patient's physical abilities or medical problems.
There is no noted description on the appeal in regard to why additional services are being requested or medically necessary.
The hours provided are adequate to meet the patient's medical need. There was some decline between the two evaluations between September and February; however, the provided number services adequate to meet this need. The additional services noted more time for IADLs along with certain ADLs. There is no specific information provided on the appeal or from the patient's physician noting why the patient would need additional hours, beyond those being provided.