Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, diabetes, osteoarthritis
Treatment: Increase Home / Personal Care Home Health Care (HHC) to 75 Hours per Week
The insurer denied:  Increase Home / Personal Care Home Health Care (HHC) to 75 Hours per Week
The denial is upheld.

The patient is an elderly female with multiple medical comorbidities including dementia, diabetes, osteoarthritis, coronary artery disease, and hypertension who is currently receiving 55 hours per week of consumer directed personal assistant services (CDPAS).  The request is for an increase in Home/Personal Care Home Health Care (HHC) to 75 Hours per Week.  

Uniform Assessment System (UAS) evaluation completed recently shows the patient has minimally impaired cognition with unchanged decision making from 90 days ago.  She lives with her family.  She requires total assistance with housework, shopping, meal preparation, toileting and bathing.  She requires maximal assistance with hygiene and dressing her upper body.   She requires extensive assistance with walking, toilet transfer, and eating.  She wears pullups for incontinence.  A tasking tool noted an estimated 38.3 hours of total weekly time for aide services, whereas a tasking tool completed recently estimated 49.42 hours per week.  

A physician letter noted that the patient required additional home health hours to assist in activities, as her medical issues are getting worse, and she is unable to perform most activities of daily living.

An initial adverse determination stated that the current 55 hours per week of Home Care/Personal Care would remain the same, as the recent assessment showed no changes in social circumstances and that safety monitoring is not a separate task.  The patient appealed this decision.  The plan upheld the denial in a letter noting that a task-based assessment tool was unchanged in calculated hours; Nursing Facility Level of Care (NFLOC) score was increased; and there was no increase in time required to assist with tasks.

The proposed treatment is not medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  This patient has requested an increase in home/personal care to 75 hours per week from 55 hours per week.  While the accompanying physician letter notes that the patient needs more assistance due to difficulty in performing her activities of daily living, the submitted documentation does not reflect which activities of daily living cannot be completed with the current 55 hours.  Moreover, as noted by the health plan, the time-based tool completed recently reflects that allocated time for each of the patient's activities of daily living amounts to 49.42 hours per week, which is less than the currently provided 55 hours.  Additionally, the patient is noted to be part of the consumer directed personal assistance program, which allows for flexibility in allocation of hours such that the patient's representative can split and arrange the existing 55 hours to meet needs throughout the day.  Based on the available information, the current 55 hours per week of personal care services are sufficient to adequately meet the patient's needs.  Thus, the increase in home / personal care to 75 hours per week is not medically necessary.