Diagnosis: Coronary artery disease, hypertension, gastroesophageal reflux disease (GERD), asthma, osteoarthritis, and diabetes
Treatment: Increase Home Health Aide Services to 40 Hours
The insurer denied: Increase Home Health Aide Services to 40 Hours
The denial is upheld

This adult female patient has medical conditions including coronary artery disease, hypertension, gastroesophageal reflux disease (GERD), asthma, osteoarthritis, and diabetes. She is appealing denial of an increase in home health aide services to 40 hours. Uniform Assessment System evaluation dated earlier this year shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing medications and transportation; limited assistance with managing finances, phone use, bathing, lower body dressing, and toileting; and independent with personal hygiene, upper body dressing, walking, locomotion, bed mobility, and eating. She has frequent bladder incontinence.

The proposed 40 hours of home health services are not medically necessary.

Personal assistance services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions. She is appealing the denial of an increase in home health aide services to 40 hours. Uniform Assessment System evaluation dated earlier this year shows the patient needs assistance with meal preparation, housework, shopping, managing medications, transportation, managing finances, phone use, bathing, lower body dressing, and toileting. She is independent with personal hygiene, upper body dressing, walking, locomotion, bed mobility, and eating.

There are no provider records or appeal statements. The information provided does not support that the patient has functional needs requiring home health aide services to 40 hours. Home health aide services are not indicated when no tasks are being performed. The level of services needed for assistance as noted above do not require 40 hours of home health aide services. The proposed increase in home health aide services to 40 hours is not medically necessary.