Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Muscle weakness, pain, osteoarthritis, and dizziness.
Treatment: Increase Home/Personal Care HHC (Home Health Care) Level 2 Services per 15 minutes to 45 hours Per Week.
The insurer denied: Increase Home/Personal Care HHC (Home Health Care) Level 2 Services per 15 minutes to 45 hours Per Week.
The denial is upheld.

This elderly female is appealing the denial of an increase in home/personal care services to 45 hours per week. The health plan approved 35 hours per week. The plan denied an increase in hours based on the Uniform Assessment System (UAS) assessment. It is noted that the patient does not have a loss of motor function. The patient had a recent fall that resulted in left arm fracture that required surgical treatment and therapy. Other medical conditions include hypertension, asthma, hyperlipidemia, muscle weakness, pain, osteoarthritis, and dizziness and giddiness. Uniform Assessment System (UAS) evaluation completed 3 months ago showed modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing medications, stairs, transportation, bathing, personal hygiene, dressing, and toileting; limited assistance with managing finances, phone use, walking, locomotion, and bed mobility; and limited assistance with eating. She has occasional bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been an improvement with meal preparation, housework, managing medications, shopping, and a decline with personal hygiene, upper body dressing, toilet transfer, and bed mobility. There is a letter from the patient's physician reporting that the patient has severe arthritis and needs a knee replacement. She has low back pain. She needs help with activities of daily living. Additional hours are recommended to avoid unnecessary risks to her health.

The proposed treatment is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple medical conditions, including a recent arm fracture after a fall. She is appealing the denial of an increase home/personal care services to 45 hours per week. The health plan approved 35 hours per week based on lack of loss of motor function. Uniform Assessment System (UAS) evaluation completed 3 months ago showed the patient requires assistance with all activities of daily living. Compared to Uniform Assessment System evaluation completed last year, there has been an improvement with meal preparation, housework, managing medications, and shopping, and a decline with personal hygiene, upper body dressing, toilet transfer, and bed mobility. There is an appeal statement requesting additional hours to help with activities of daily living and to avoid health risks. The Uniform Assessment System evaluations do show the patient continues to require assistance with activities of daily living. However, the current Uniform Assessment System evaluation is favorable regarding improvement in functioning. The decline in personal hygiene, upper body dressing, toilet transfer, and bed mobility is consistent with the recent upper extremity fracture for which she is receiving therapy. Personal care services are not indicated for management of medical conditions or for supervision. Additional hours are not supported for assistance with the same activities of daily living as previously approved. The approved personal care service hours of 35 hours per week is appropriate. The increase in personal care service hours of 45 hours per week is not medically necessary.