This is a patient with a significant past medical history, most notably for dementia and generalized deconditioning. Live-in 7 days a week ×24 hours a day consumer directed personal care was requested. This was denied based upon medical necessity. Patient is currently approved for 42 hours a week, 7 days a week × 6 hours per day. The health plan's determination is upheld.
Additional personal care services are not medically necessary in regards to the performance of activities of daily living (ADLs) or instrumental activities of daily living (IADLs).
This is a patient with a past medical history significant for coronary artery disease, cardiomyopathy, chronic obstructive pulmonary disease (COPD), hypertension, dementia, gastroesophageal reflux disease, headache and osteoarthritis.
Her health plan approved 42 hours a week. She had a Uniform Assessment System (UAS) State of NY. The testing assessment tool noted to the patient required an average of 3 hours a day ×7 days a week for total of 21 hours a week to meet her needs including ADLs and IADLs. The patient has memory issues, but she is able to ambulate independently in her residence. She did have a hospitalization with a diagnosis of pneumonia and a brain lesion. It was noted at that time that the patient was able to eat without help, she was able to use the bathroom with a little help, but she did need help with shopping, housework and preparing meals. It was noted that the patient was safe to be left alone. Personal care hours for safety monitoring and/or companionship are typically not considered medically necessary without the necessity of completing a specific task such as an ADL or IADL. Based upon the documentation provided, the current level of personal care services are adequate to meet the patient's necessity for ADLs and IADLs. Additional personal care services are not medically necessary.