Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Schizophrenia; Diabetes; Prior stroke; Hypertension; Hypothyroidism; Atrial fibrillation
Treatment: Increase Home/Personal Care Level 2 per 15minutes to 70 Hours Per Week
The insurer denied Increase Home/Personal Care Level 2 per 15minutes to 70 Hours Per Week.
The denial is upheld.

This patient is an adult female diagnosed with schizophrenia, diabetes, prior stroke, hypertension, hypothyroidism and atrial fibrillation. The request is for an increase in Home/Personal Care Level 2 per 15 minutes to 70 Hours per Week. An initial adverse 
determination noted that the patient had no change in her overall self-sufficiency per the most recent nursing assessment. A final adverse determination was issued, noting that the increase from the currently approved 49 hours per week was not considered medically necessary, and that "The personal care hours are currently authorized in the amount, duration and scope necessary to meet this member's personal care needs." In a physician letter, the provider notes that the patient has multiple chronic medical conditions and requires assistance with her activities of daily living, including cooking, cleaning, grocery shopping, and getting to appointments. The note reflects that the patient can bathe, dress, and feed herself. She walks with a cane indoors. A nursing assessment dated 6 months ago notes that the patient requires maximal assistance for meal preparation and shopping. She is totally dependent for housework. She requires extensive assistance with managing her medications and bathing, as well as lower body dressing. She requires minimal assistance for dressing upper body, personal hygiene, walking, and toilet use. She is set up only for eating and bed mobility. A NFLOC (Nursing Facility Level of Care) assessment was performed, which resulted as a score of 20. A previous nursing assessment performed over 3 years ago, noted a score of 21. An Aide Tasking Tool dated 6 months ago estimates that the total weekly time spent on addressing the patient's needs is 33.83 hours. The request for increased hours for in home/personal care assistance is under review.

The requested health service of an Increase Home/Personal Care Level 2 per 15minutes to 70 Hours per Week, is not considered 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 request 
is for an increase in Home/Personal Care Level 2 per 15 minutes to 70 Hours per Week from 49 hours per week. The submitted documentation does not reflect which activities of daily living cannot be completed within the currently approved 49 hours per week. The provider notes that the patient needs assistance with "cooking, cleaning, and grocery shopping." However, time for 
housework, meal preparation, personal hygiene, shopping, toileting, and dressing, have already been accounted for in the hours approved by the plan. The patient is also noted to have equipment at home to assist with her activities of daily living, and to keep her safe, including a cane and walker. Additionally, the nursing assessment from 6 months ago notes a Nursing Facility Level of Care Score (NFLOC) of 20, which is relatively stable from the score of 21 on the patient's prior assessment, 
indicating that the patient's functional status has not significantly changed. As such, additional hours beyond those currently supplied by the plan would be for safety only; however, personal care services are not covered for supervision and safety concerns, per New York State Guidelines. As such, based on the available information, the plan's initial denial rationale is appropriate, and 49 hours per week of Home/Personal Care Level 2 hours are sufficient to meet the patient's needs. Thus, the increase in Home/Personal Care Level 2 per 15 minutes to 70 Hours Per Week is not considered medically necessary.