Diagnosis: Cardiac/Circulatory problems.
Treatment: Home Health Care.
insurer denied increase in home health hours to 56 hours per week.
The denial is upheld.

The patient is a female with a past medical history significant for heart failure, depression, diabetes, osteoarthritis, lymphoma, hypertension, hearing loss and chronic pain.
This review is for the medical necessity of increase in home care hours from 42 hours a week to 56 hours a week. The patient currently receives 6 hours a day ×7 days a week. The patient is requesting an increase to 8 hours a day ×7 days a week. These services were denied based on medical necessity. Patient is appealing the decision.

The health plan's determination is upheld.

The requested increase in hours is not medically necessary for this patient.

Based upon the most recent assessment, patient is able to feed herself when meals are prepared. The patient needs extensive assistance with bathing and dressing lower body. The patient needs assistance with dressing upper body. She is able to do personal care with limited assistance. She uses a cane for ambulation. The patient also uses a Rollator for ambulation. Her last assessment noted that she was stable.
The patient is currently receiving 42 hours a week of services. She had an assessment and a reassessment done. She had a tasking tool performed. There were no significant changes noted in the patient's medical condition. The most recent tasking tool noted patient required assistance with both level 1 services and level 2 services. It was noted that the patient is having more trouble with ambulation but is still able to ambulate with a Rollator walker. Since the patient is still able to ambulate independently inside her place of residence, and her medical condition did not significantly change her level need did not significantly change. She still requires level 1 services which are being provided and did not change. The level 2 services did not significantly change between assessments. There is no medical need demonstrated in the physician appeal, the patient appeal, or the other assessments which would necessitate additional home care hours.