Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Home Health Care; 12 hours per day 7 days per week (Monday through Sunday), a total of 84 hours per week.
The insurer denied Personal Care Assistance Service; 12 hours per day 7 days per week (Monday through Sunday), a total of 84 hours per week.
The denial is upheld.

The patient is a female with a past medical history significant for a fall. The patient is noted to have 2 separate falls in 8 days and found on the floor by her daughter. The patient is unable to get up on her own. She is unable to stand alone. The patient lives alone.
The patient is currently receiving 29 hours a week, and there is a request is for an increase to 12 hours a day times (×) 7 days a week for a total of 84 hours a week. This was denied by her health plan for medical necessity. Services were denied by her health plan stating the daughter asked for an increased due to a recent fall, as the patient may have tried to stand and lost her balance falling and sustained swelling and a bump on her forehead. The patient is more disoriented and does not follow directions, and her gait is unsteady. A review of her assessment and care plan resulted in a recommendation to continue the patient's current hours. The patient is appealing the decision.
At issue is the medical necessity of Personal Care Assistance Service; 12 hours per day 7 days per week (Monday through Sunday), a total of 84 hours per week.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Personal Care Assistance Service; 12 hours per day 7 days per week (Monday through Sunday), a total of 84 hours per week is not medically necessary for this patient.
New York state regulations do not require personal care assistant services for safety and supervision alone, such as may be clinically necessary for someone with cognitive dysfunction. Personal care assistant hours for companion care or for safety supervision, without the need for activity of daily living tasks, is not required to be covered. Cognitive and prompting is included as part of another task and is not a specific standalone task required to be performed by a personal care assistant. The patient is noted to have a stage I decubitus on her right buttock. The patient currently has a hospital bed with alternating pressure mattress. She is noted to be incontinent. The patient is requesting 7 days a week × 24 hours a day as services. It was stated that the patient lives alone. It is not clear from the patient's appeal letter that she does need 12 hours per day ×2 split shift services and there is no documentation supporting this. There is no medical documentation noting the necessity for continuous care.
Therefore, the requested health service/treatment of Personal Care Assistance Service; 12 hours per day 7 days per week (Monday through Sunday), a total of 84 hours per week is not medically necessary.