Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 
The insurer denied 70 hours a week consumer directed assistance program services. The denial is overturned in part. 

The patient is a male with past medical history significant for cerebrovascular disease, coronary artery disease, hypertension, hyperlipidemia, diabetes and valvular heart disease. The patient is currently approved for 5 hours a day 7 days a week for a total of 35 hours a week. The patient is requesting 10 hours per day 7 days a week for a total of 70 hours a week. This was denied by the health plan based upon lack of medical necessity. The medical necessity for the increased hours is the subject under review.

The health plan's determination is overturned in part. 

The patient is currently receiving 35 hours per week. The requested 70 hours a week is not medically necessary, however 49 hours a week is medically necessary.
Physician office notes were reviewed. The Office note indicates that the patient is clinically stable. The patient is able to brush his teeth and feed himself. He still needs help with bathing and toileting because of balance problems. He is walking with walker. Office note indicates the patient is continuing to improve but is still weak on the right side, he is walking with walker.
Uniform Assessment System (UAS) State of New York were reviewed. The client task sheet recommended services are needed due to help toileting, bathing, meal preparation and bed linen changes. The patient is functionally limited by hemiparesis on the right side following a cerebrovascular accident (CVA) in 2019.
Services were denied based upon the following. Patient requires extensive assistance for personal hygiene, bed mobility, walking, locomotion, toilet transfer and medication management. Patient requires maximal assistance for dressing upper and lower body, bathing, toilet use and meal preparation, meaning you need physical help to complete most parts of this tasks like someone to lean on or help you of the body part, however he can complete some parts of this task by himself. The patient is able to direct his own care. The patient lives with his son/personal assistant who is supportive and involved in the care. Based on the patient's personal care needs they can be met with 5 hours a day 7 days a week for total of 35 hours a week.
The patient lives with his son in a 2 bedroom apartment. The patient's son assists with his father's activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) when an aide is not present.
From review of the notes provided along with the nursing assessment, it appears that the patient has not had any new events/strokes or other neurological changes. The patient had a stroke resulting in weakness, hemiparesis along with generalized debility. The patient had two evaluations done. There appears to be some progression of the decline in the patient's overall level of function. This requires extra time as noted through the tasking tool provided. This notes that 45 hours a week are recommended. The patient is currently receiving 35 hours a week. 49 hours a week would be reasonable to meet the patient's functional needs which have declined since his stroke.