Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Home Health Care.
The insurer denied increase in personal care assistance hours to 7 days a week 12 hours a day.
The denial is upheld.

The patient is a female with a past medical history significant for dementia, hypertension, hypertensive heart disease, coronary artery disease, congestive heart failure, hyperlipidemia, hypertensive nephropathy, osteoarthritis and osteoporosis. The patient is receiving Personal Care Assistance (PCA) hours 7 days a week 9 hours a day.
The subject under review is the medical necessity for the request for increase in hours to 7 days per week 12 hours per day. An increase in services was denied by the health plan based on lack of medical necessity.

The requested health service is not medically necessary for this patient.
The services currently being provided are adequate to meet the patient's need in the allotted time. Additional hours are not medically necessary.
The patient is currently approved for 63 hours per week. The patient is requesting 84 hours a week. This was denied based upon lack of medical necessity.
An increase in personal care services was denied by the health plan stating patient does not meet criteria. No changes were noted in activities of daily living with exception of bathing and personal hygiene. Dressing lower body showed improvement. The patient is able to ambulate with a walker. There is no reported significant changes noted in the patient's medical condition. The appeal noted that the patient needs increased hours for medication reminders.
Uniform Assessment System (UAS) State of New York were reviewed from both dates of assessment. The physician statement was reviewed. An appeal request was reviewed.
There has not been a significant change in the patient's physical status between the two assessments which were listed. It was noted on the appeal that the patient needed reminders taking medications and needs help with all locomotion.
However, according to the assessment, the patient is able to ambulate with a walker. There is no reported significant changes noted in the patient's medical condition. The patient ambulates indoors with a cane or walker. She is self-directed with care. No recent hospitalizations or falls were noted. She had a fall 2-1/2 months ago at home. There was noted frequent incontinence of urine. No pressure ulcers were noted. She requires extensive assistance with most activities of daily living (ADLs). The patient was observed transferring from sitting to standing holding her walker and ambulating. The statements appear similar between the two reports.
The service hours currently provided are adequate to meet the patient's medical needs in the time noted. Additional services for "prevention of falls" for "monitoring" without services being provided are typically not covered. In order for services to be considered medically necessary, the aide must be performing a service such as medically necessary activities of daily living (ADLs) or Instrumental activities of daily living (IADLs).