The patient is a male with a past medical history significant for malignant anaplastic oligodendroglioma. This review is for the medical necessity of personal care aide level 2, 14 hours per day ×7 days a week for a total 98 hours per week. The plan approved 7.5 hours a day ×7 days a week for total 52.5 hours per week. The patient requested additional hours. The plan approved 8.5 hours per day ×7 days a week for a total 59.5 hours per week. The subject under review is the medical necessity of the requested 98 hours per week.

The health plan's determination is upheld, in whole.

No, the requested health service/treatment of Personal Care Aide Level 2, 14 hours/days 7 days per week total of 98 hours per week is not medically necessary for this patient.
The patient has a malignant brain tumor status post chemotherapy along with primary resection. He has progressive left-sided weakness prompting a repeat resection of tumor. Evaluation for services was dated prior to the surgery. Due to the patient's progression of the tumor and symptomatology including left-sided hemiparesis and focal seizures, the patient would benefit from additional hours of service, however, 98 hours per week is not medically necessary. Given that there has been a significant change in symptoms, a reevaluation secondary to the change in his medical status may be of consideration.

The prior Uniform Assessment (UA) noted a total of 52.5 hours per week of level 2 aide hours. That was sufficient for his care needs at that time.