Diagnosis: Cardiac/Circulatory Problems.
Treatment: Home Health Care.
The insurer denied Personal Care Assistance Services, total of 112 hours per week.
The health plan's determination is upheld in whole.

The patient is a male a with a past medical history of diabetes type 2, obesity, coronary artery disease, pacemaker, osteoarthritis, and hypertension who had been assigned personal care services. The patient underwent an assessment for personal care assistance services. The patient lives at home alone. Regarding his functional status, he is minimally impaired with no memory problems, he is able to communicate and understand others. He has minimal vision and hearing difficulty. He requires assistance with Instrumental Activities of Daily Living (IADLs) as follows: maximal assistance with meal prep, maximal assistance with housework; limited assistance with managing medications and finances, extensive assistance with stairs, and maximal assistance for shopping and extensive assistance for transportation.
He requires assistance with Activities of Daily Living (ADLs) as follows: extensive assistance with bathing, limited assistance with personal hygiene, dressing upper body, extensive assistance needed for dressing the lower body, locomotion, and walking, limited assistance with toileting transfers, toilet use, and bed mobility and independent with eating. He uses a cane for mobility and a rollator has been ordered. He is occasionally incontinent with bladder and continent with bowel. ADL status in the last 90 days is unchanged. One fall in the last 30 days. He has diminished energy and is unable to complete day-to-day activities. He has no pressure ulcers. Per assessment, he required about 20 hours of personal assistance services. He has a cane, shower chair, and grab bars.
Prior assessment completed determined that patient required 29 hours of personal assistance services.
This review is for the medical necessity of request to increase personal care assistance services to 112 hours per week.

The health plan's determination is upheld.

The requested health service of personal care assistance services for 112 hours per week is not medically necessary for this patient. Per assessment, the patient requires extensive assistance with bathing, dressing lower body, locomotion and walking and, limited assistance with personal hygiene, dressing the upper body, toileting transfers, toilet use, and bed mobility. There is no documented acute decline in functional status or documentation that the patient needs additional assistance that would be medically necessary for the patient above and beyond those documented with the previous nursing assessments that would require up to 112 hours per week.