202103-136229
2021
Empire BlueCross BlueShield HealthPlus
Medicaid
Central Nervous System/ Neuromuscular Disorder
Home Health Care
Medical necessity
Upheld
Case Summary
Central Nervous System
Home Health Aide
Diagnosis: Parkinson's
Treatment: Personal Care Services
The insurer denied Personal Care Services: 70 Hours per Week. The health plan's determination is upheld.
This patient is a female. She has a past medical history for Parkinson's disease, depression, gait abnormality, hypertension, gastroesophageal reflux disease, osteoarthritis and hyperlipidemia. The patient has been approved for 17 hours per week.
Under review is the medical necessity of Personal Care Services: 70 Hours per Week.
Personal Care Services: 70 Hours per Week is not medically necessary for this patient.
The Patient is a female with multiple medical problems. She has a long-standing history of Parkinson's disease for at least 10 years. She has movement and gait abnormality secondary to Parkinson's disease along with several other conditions from the disease and complications of medical therapy. She is requesting additional home health services through her power of attorney. She suffered from coronavirus with complications resulting in long hospitalization and nursing home stay the previous year. She did eventually recover and returned home. Physical therapy and occupational therapy were offered but refused by the patient until she was vaccinated for coronavirus.
An office note by the patient's primary care provider states that the patient requires a rolling walker to ambulate. She is in no distress. A review of systems was negative for dizziness, weakness or headaches and negative for depression. Vital signs are stable. Neurological exam states no focal deficit, she is alert and oriented to person, place and time. Mental status is at baseline. Behavior is normal.
Neurological exam states that the patient walks slowly and may shuffle with short steps. Uniform Assessment System (UAS) State of New York recommended 17 hours per week of services. Personal hygiene was noted to be limited assistance. Bed mobility and eating were noted to be independent with set up only. The patient uses a wheelchair for long distance and a walker for short distance.
It is reasonable to say that the patient's medical needs are met by the amount of services listed. Additional services are requested to help the patient prevent falls and so that she would not be alone. They were not necessarily requested for additional tasking, activities of daily living (ADLs) or instrumental activities of daily living (IADLs). The services for ADLs and IADLs were met with the amount of time available as listed through the UAS and also the tasking tool. Additional services for "prevention of falls" for "monitoring" without services being provided are typically not indicated. In order for services to be considered medically necessary, the aid must be performing a service such as medically necessary ADLs or IADLs.