Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 

Treatment: Home Health Care. 

The insurer denied of Level 2 Personal Care Aide Services (7 hours per day, 6 days per week). 

The denial is upheld. 

The patient is a female with past medical history significant for diabetes mellitus type 2, diabetic neuropathy, anxiety disorder, depression. 
This review is for the medical necessity of increase in personal care aide services to 7 hours per day 6 days a week. Increase in services was denied by the plan based upon lack of medical necessity. The patient is currently approved for 24 hours a week of services. 

The health plan's determination is upheld in whole. 

The requested health service is not medically necessary for this patient. 

Additional services are not medically necessary. 24 hours week of services are sufficient for the patient's needs. Services were denied by her insurance plan stating that the patient is approved for 4 hours per day  6 days a week for a total of 24 hours a week of services, and the patient's current services are appropriate to meet the patient's needs. 

The patient requests additional services for help cooking, cleaning, showering and going to medical appointments. The patient is requesting additional services because she falls in her home, and she is frail according to her appeal. 
It is noted that the patient is able to walk by herself with an assistive device with little help. She is able to direct her own care. She is able to wash her face, brush her teeth, dress her upper body, get on and off the toilet and eat without help. She is able to take a bath and dress her lower body with little help. Additional services for safety monitoring and/or for the aide to accompany the patient to medical appointments does not qualify for additional services. 
The physician noted the patient requires at least 6 hours a day as services for help with her activities of daily living (ADLs). Her physician noted the patient was admitted to the hospital for pneumonia and discharged. 
The tasking tool noted the patient requires a total 17.7 hours a week. Most of the services required include services for meal preparation, shopping and ordinary housework. 
The Uniform Assessment System (UAS) State of New York was reviewed. 
The patient did have a hospitalization secondary to pneumonia a few months ago which was after the nursing assessment, however there is no specific notation of additional services that the patient might need because of the pneumonia. The patient requests additional services due to frailty. Her physician requests additional services because she needed help with ADLs. 
The services which required the most assistance for the patient included Instrumental activities of daily living (IADLs), specifically, cooking and cleaning and other household chores. It is not indicated in the information provided that additional services for specific ADLs such as personal hygiene and toileting or transferring, or her walking were impaired or decreased from the recent hospitalization. The amount of services provided from the nursing assessment are sufficient to meet the patient's needs. When approving services, there must be a demonstrated need for ADLs or IADLs above and beyond observation and preventing falls. Services for preventing falls and observation are typically included in the provided services allowed for under the evaluation. Specifically, the aide must be performing a service such as in ADL or IADL to be a covered service.