202005-128242
2020
Healthfirst Inc.
Medicaid
Cancer, Orthopedic/ Musculoskeletal
Home Health Care
Medical necessity
Upheld
Case Summary
Diagnosis: Leukemia, chronic low back and bilateral
knee pain.
Treatment: Consumer Directed Personal Care Assistance Services 25 hours/week .
The insurer denied the Consumer Directed Personal Care Assistance Services 25 hours/week.
The denial is upheld.
No, the proposed treatment of an increase in Consumer Directed Personal Care Assistance Services to 25 hours/week is not deemed medically necessary.
The patient is a female with a history of leukemia, chronic low back and bilateral knee pain. Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs), bed mobility, transfers and ambulation.
Appeal review requested for potential approval of an increase in Consumer Directed Personal Care Assistance Services to 25 hours/week to offer increased ADL assistance.
Due to impairments related to these conditions, she requires assistance for completion of many of her ADLs, bed mobility, transfers and ambulation. However, an in home assessment of the patient's functionality and clinical status was completed and revealed that the currently approved plan of 23 hours/week Consumer Directed Personal Care Assistance Services is sufficient to meet the patient's current needs. There is no additional documentation which indicates that the patient has sustained additional functional decline since the date of this last assessment. For these reasons, the proposed treatment of an increase in Consumer Directed Personal Care Assistance Services to 25 hours/week is not deemed medically necessary.