Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Home health care.
The insurer denied Increase in personal care hours to 69 per week.
The denial is upheld.

The patient is a female with past medical history significant for Charcot-Marie-Tooth disease, spinal stenosis, hypertension, hyperlipidemia, depression, and epilepsy. The patient is requesting Personal Care Aide Level II 69 hours per week, 9-10 hours per day, 7 days per week. The patient is currently receiving 56 hours per week. This was denied by the health plan as not medically necessary.

The health plan's determination is upheld in whole.

The additional Consumer Directed Personal Assistance Services (CDPAS) are not medically necessary for this patient.
The patient is a female with past medical history as listed above with progressive neurological disorder resulting in generalized medical decline and debility. Additional services were denied by her insurance stating due to lack of medical necessity.
Uniform Assessment System (UAS) State of New York were reviewed. When comparing assessments done there does not appear to be a significant decline in the patient's medical status.
The personal care tasking tool notes a total of 8 hours per day ×7 days a week for total of 56 hours a week of services. The personal care tasking tool dated months earlier notes a total of 8 hours per day ×7 days a week for a total of 56 hours a week of services.
Physical exam noted that the patient's skin was warm and dry. Assessment noted stage I pressure ulcer on the left buttock with recommendations for an egg crate pad for the chair.
There is a physician's statement stating that the patient's condition was stable, with need for assistance with all activities of daily living (ADLs).
The patient currently receives 56 hours a week of services and is requesting an additional 13 hours a week of services.
According to the appeal and the documentation provided there are no services that are being requested that could not be provided during the allotted time. Specifically, the patient has been allotted 56 hours a week divided over 7 days for services including ADLs and instrumental activities of daily living (IADLs). The patient's health status according to the assessment provided did not change significantly. The patient did have increasing weakness and a stage I pressure ulcer. The stage I pressure ulcer was recommended to be treated with an egg crate pad on her chair, however this did not specifically affect or increase the necessity for utilization of requested services. In order for services to be considered medically necessary, the aide must be performing a service such as a medically necessary ADL or IADL.