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202207-151181

2022

Senior Health Partners

Managed Long Term Care

Orthopedic/ Musculoskeletal

Home Health Care

Medical necessity

Upheld

Case Summary

Diagnosis: Orthopedic/Musculoskeletal/Osteoarthritis.
Treatment: Home Health Care.

The health plan denied the requested increase in personal care assistant services. The health plan's determination is upheld.

The patient is a female with a past medical history of stroke, diabetes, chronic kidney disease, and auditory hallucinations.

The patient was assigned services based on an assessment, assessing the patient to be minimally impaired with memory problems, moderate hearing difficulty and moderate vision difficulties. The patient was assessed to be totally dependent with the task of meal preparation and housework, and extensive assistance with medications and shopping. The patient was assessed at extensive assistance with tasks of bathing, personal hygiene, dressing upper body and dressing lower body, limited assistance with walking toilet use and transfers, limited assistance with bed mobility and limited assistance with eating. The patient is frequently bladder incontinent and occasionally bowel incontinent.
The patient's primary care provider wrote a letter of medical necessity. The physician noted that the patient has multiple medical problems and is functionally and cognitively impaired and requires assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The physician also stated that patient suffers hallucinations at night and is reassured with companionship.

The patient was evaluated by her primary care physician, who noted that the patient continues to suffer from visual and auditory hallucinations and a declined psychological evaluation. Hallucinations are worse at night.

This review is regarding the medical necessity for an increase in Personal Care Aide (PCA) services to 24 hours per week, live in Monday-Sunday. The patient is currently approved for 56 hours weekly.

The health plan's determination is upheld, in whole.

The requested service is not medically necessary.

The patient requires assistance for activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Based on the Uniform Assessment System (UAS), she was assessed to require 31 hours of assistance. The patient has not had any recent hospital admissions or new documented change in functional status to require an increase in hours. The patient needs limited assistance with toileting and bed mobility. It is documented that the patient does suffer from hallucinations, however, given that there is no documented need for tasks to be done during nocturnal hours, additional hours are not necessary.

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