Diagnosis: Coronary artery disease, diabetes mellitus, depression

Issue under review: Personal care assistance, level II services to five hours/day, two days/week (Monday and Tuesday), four hours/day, three days/week (Wednesday, Thursday, Friday) and eight hours per day, two days/week (Saturday and Sunday), for a total of 38 hours/week

The insurer denied the Personal care assistance, level II services to five hours/day, two days/week (Monday and Tuesday), four hours/day, three days/week (Wednesday, Thursday, Friday) and eight hours per day, two days/week (Saturday and Sunday), for a total of 38 hours/week

The denial is upheld.

No, the proposed treatment of an increase in personal care assistance, level II services to five hours/day, two days/week (Monday and Tuesday), four hours/day, three days/week (Wednesday, Thursday, Friday) and eight hours per day, two days/week (Saturday and Sunday), for a total of 38 hours/week is not deemed medically necessary.

This is a female with a history of coronary artery disease, diabetes mellitus and depression. Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs). However, an in home assessment of the patient's overall functionality and ability to complete ADLs was performed and revealed that the currently approved plan of personal care assistance, level II services 22 hours/week is sufficient to meet the patient's current needs. There is no additional documentation noted since the date of this last assessment which demonstrates that the patient has sustained additional functional decline which would warrant an increase in PCA hours. For these reasons, the proposed treatment of an increase in personal care assistance, level II services to five hours/day, two days/week (Monday and Tuesday), four hours/day, three days/week (Wednesday, Thursday, Friday) and eight hours per day, two days/week (Saturday and Sunday), for a total of 38 hours/week is not deemed medically necessary.