Diagnosis: Pancreatic cancer, dementia, hypertension and atrial fibrillation

Treatment Home Care/Personal Care HHC (home health care) - Level 2 personal care services, per 15 minutes increase to 24 hour(s) per day (split shift); CDPAS (consumer directed personal assistance services).

The insurer denied coverage for Home Care/Personal Care HHC - Level 2 personal care services, per 15 minutes increase to 24 hour(s) per day (split shift); CDPAS

The denial is upheld

This is a patient with dementia, atrial fibrillation and history of pancreatic cancer. She requires nasal oxygen. She lives with her husband. The patient's services were increased from 44 hours/week to 84 hours/week. However, the patient, through her representatives requested an increase to 24 hour(s) per day (split shift); CDPAS which is under review.

According to the Uniform Assessment System (UAS) report, the patient is totally dependent for ordinary housework, meal preparation and shopping. She requires extensive assistance for bathing, lower body dressing and toilet use. She is bladder and bowel incontinent. She requires limited assistance for upper body dressing and supervision for ambulation. The combination of the patient's limited functional ability and dementia supports the increase from 44 hours/week to 84 hours/week, in order for her to continue living safely at home. The patient's condition is progressive, and this physician recommends a follow-up assessment in six months.

From a physical medicine and rehabilitation perspective, the patient's service increased from 44 hours/week to 84 hours/week was clinically appropriate. However, Home Care/Personal Care HHC - Level 2 personal care services, per 15 minutes increase to 24 hour(s) per day (split shift); consumer directed personal assistance services (CDPAS) is not supported as medically necessary at this time. This physician recommends a 6-month follow-up assessment from the prior assessment.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Home Care/Personal Care HHC - Level 2 personal care services, per 15 minutes increase to 24 hour(s) per day (split shift); consumer directed personal assistance services (CDPAS) is upheld. Medical Necessity is not substantiated.