Diagnosis: Respiratory System
Treatment: Home Health Care
The insurer denied increase in consumer directed personal assistance program 84 hours per week.
The decision is upheld.

The patient is a female with past medical history significant for asthma/chronic obstructive pulmonary disease (COPD), osteoarthritis and ambulatory dysfunction. This review is for the medical necessity of consumer directed personal assistant program hours, 12 hours per day x (times) 7 days a week for a total 84 hours a week. The patient has been approved for a total of 63 hours, which is an increase from 52.5 hours a week. Services were denied based upon medical necessity. The subject under review is the medical necessity for the increase in hours.

No, the requested health service is not medically necessary for this patient. Additional services were denied by the patient's insurance stating the following: Additional services were requested by the patient's son because of a significant change in your mother's physical condition for quite some time. She cannot sit or get up from a chair alone, walk with a cane or walker or even stand for a minute, positioning, take medicines, pick up anything from the floor while seated, cook, hold a glass, turn pages, get dressed, clean herself, eat meals, dial phone number, or comb her hair. You stated that she needs assistance with functions of daily living.

The Uniform Assessment System (UAS) State of New York, stated some of your mother's personal care needs stayed the same and some declined. Mother's abilities to perform daily activity is the same for dressing upper body, personal hygiene, walking, locomotion, bathing, toilet transfer, meal preparation and housework. Your mother's abilities to perform daily activities declined in dressing lower body, bed mobility, toilet use, eating, and medication management. Your mother lives with her 2 sons and daughter and her children are supportive and involved in her care. Granting additional hours for safety monitoring and supervision are not covered services and not medically necessary. The plan approved 9 hours per day x7 days a week for a total of 63 hours a week.

The services provided, 63 hours a week of consumer directed care services, are adequate to meet the patient's needs and considers the patient's functional disabilities and physical decline. Services beyond 63 hours are not medically necessary. Additional services for prevention of falls, for supervision or monitoring without services being provided, are typically not necessary. In order for services to be considered medically necessary, the aide must be performing a service such medically necessary activities of daily living (ADLs) or instrumental activities of daily living (IADLs).