Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Home Health Care. 
The insurer denied increase in personal care worker services to 24 hours per day live-in services; 91 hours a week. 
The health plan's determination is upheld.

The patient is a female with past medical history significant for cerebellar mass, determined to be central nervous system (CNS) lymphoma treated by surgical resection and subsequent chemotherapy. The patient was receiving 5 days a week  6 hours per day and 2 days per week 5 hours a day for a total of 40 hours per week. The plan approved 7 days a week 8 hours a day for total of 56 hours a week a personal care worker service. The request for 24 hours per day live-in services for 91 hours a week was denied by the plan based upon lack of medical necessity. The subject under review is the medical necessity for the increase in hours to 24 hours per day live-in services; 91 hours per week.

The health plan's determination is upheld. 

Additional personal care worker services greater than 56 hours a week are not medically necessary. The information provided does not support the need for additional services beyond 56 hours a week.
The patient has a recent past medical history significant for cerebellar mass, CNS lymphoma treated by surgical resection and subsequent chemotherapy. Services were denied by her insurance stating the following: You are able to ambulate 50 feet with a roller walker and contact guard assistance, you are able to transfer and use the toilet with minimal assistance. You are able to feed herself with the meals that are prepared and set up for you in advance by her personal care worker. You are alert and oriented to person place and time and able to make needs known.
Your activity daily living needs during a calendar today such as grooming, dressing, bathing, transferring, walking, toileting, meal preparation and feeding are sufficiently infrequent and can be safely inadequate met through a combination of approved personal care worker services 7 days a week  8 hours per day.
The patient was admitted for loss of conscious is determined to be secondary to brain mass/CNS lymphoma.
The physical exam  stated that the patient was alert and oriented and in no distress. There were no focal deficits and strength was noted to be normal. 
Uniform Assessment System (UAS) State of New York were reviewed. The evaluation done by physical therapy was noted and referenced in the health plan's denial.
The patient's clinical status has deteriorated since the last nursing evaluation/UAS; however, she did have a physical therapy and occupational therapy evaluation in the hospital subsequent to surgery. The patient was able to ambulate 50 feet  2 with a roller walker. She was able to transfer and use a toilet with minimal assistance. She was able to feed herself. The patient was oriented to time and place. Physical exam noted that the patient was alert and oriented and in no distress with no focal neurological signs. The services which are medically necessary are able to be performed within the 8 hours a day  7 days a week. Additional services for monitoring and preventing falls without a specific activity of daily living (ADL) being provided or not considered medically necessary.