Diagnosis: Central Nervous System/Neuromuscular.
Treatment: Home Health Care.

The insurer denied increase in personal care assistance hours to 91 per week live in.
The denial is upheld.

The patient is a female with past medical history significant for breast cancer, hypothyroidism, dementia, depression, epilepsy, neuropathy, hypertension, cervical myelopathy, chronic subdural hematoma and abnormal gait. The patient has been approved for personal care assistance (PCA) services 7 days a week x 8 hours a week for a total of 56 hours per week. The patient is requesting an increase in hours to 7 days per week x 24 hours live in for a total of 91 hours per week. The services were denied based upon lack of medical necessity. The subject under review is the medical necessity for the increase in hours.

The Uniform Assessment System (UAS) State of New York was reviewed. The tasking tool - dated was reviewed. The UAS noted that the patient required a total of 56 hours a week for activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). This did not take into account any additional caregiver needs provided by her sister. Whether or not her sister provided informal care, documented medically necessary care was determined to be 56 hours a week. This was noted to be sufficient to meet her needs. Additional services are not medically necessary.

The services provided are adequate to meet the patient's medical needs in the time noted. Additional services for "prevention of falls" for "monitoring" due to worsening cognition without functional services being provided are typically not covered. In order for services to be considered medically necessary, the aid must be performing a service such as a medically necessary ADL or IADL.