Appeal type: Medical necessity
Decision: Overturned

Diagnosis: General debility, aphasia with hemiparesis. 
Treatment: Increase Consumer and Self-Directed Personal Assistance Program Services for a Total of 84 Hours per Week.

The insurer denied Increase Consumer and Self-Directed Personal Assistance Program Services for a Total of 84 Hours per Week.  The denial is overturned.

The patient is an elderly female with history of general debility. The request is for personal care assistance through home health care (level 2) to be increased from 48 hours per week (6.85 hours per day, 7 days per week) based on Uniform Assessment System (UAS) of 6 months ago to 84 hours per week (12 hours per day, 7 days per week) based on Uniform Assessment System (UAS) of 3 months ago. The health plan denied the request stating that the patient has a supporting son who can direct her care, is alert and oriented to person and place, able to make her needs known, express an emergency plan, etc., and that the helping aide will not help manage her medical conditions as it is outside the scope of the helping aide, and that she should continue to use her wheelchair to move around. The additional hours requested are because of the patient's chronic medical conditions, and to help with her activities of daily living (ADLs) as she requires extensive assistance with dressing, bathing, grooming, transferring, turning, positioning, toileting, ambulation, meal preparation, eating, housekeeping and shopping., etc.
A review of the records shows that the patient has multiple chronic medical conditions including age-related cerebral infarction, osteoporosis, limited mobility, wheelchair bound, aphasia with hemiparesis due to the cerebral infarction, incontinence of bowel and bladder, osteoarthritis, paroxysmal atrial fibrillation, sensorineural hearing loss, essential hypertension, glaucoma, and hyperlipidemia, etc. Uniform Assessment System - New York (UAS-NY) evaluation of 3 months ago showed that the patient required extensive assistance with mobility, walking, locomotion, transfer toilet, toilet use and eating, required maximum assistance with upper/lower body dressing, bathing, etc., while totally dependent for meal preparation, medication management and housework. Her family support is very good, as she lives with her son.

The requested health service is medically necessary.

The requested increase for personal care assistance through home health care (level 2) from 48 hours per week (6.85 hours per day, 7 days per week) based on Uniform Assessment System (UAS) of 6 months ago to 84 hours per week (12 hours per day, 7 days per week) is medically necessary because based on the most recent Uniform Assessment System of 3 months ago the patient required extensive assistance with mobility, walking, locomotion, transfer toilet, and eating upper body dressing, required maximum assistance with upper/lower body dressing, bathing, managing finances, shopping, bathing, personal hygiene, lower body dressing, toilet use, bed mobility, etc., while totally dependent for meal preparation, medication management and housework. The reason for denial by the health plan as stated in the clinical information above, does not align with the patient's disability features as stated in the Uniform Assessment System of 3 months ago as stated above. Therefore, the 84 hours per week (12 hours per day, 7 days per week) based on Uniform Assessment System of 3 months ago should be approved.