Diagnosis: Osteoarthritis and depression.

Treatment: Home health care (HHC)/ personal care - level 2 personal care services, per 15 minutes increase to 42 hours per week.

The insurer denied coverage for HHC/ personal care - level 2 personal care services, per 15 minutes increase to 42 hours per week.

The denial is upheld.

This patient is an adult with osteoarthritis and depression. She lives with her daughter and granddaughter. She is approved for personal care services (PCS) 22 hours/week and is requesting 42 hours/week.

According to the recent Uniform Assessment System (UAS) report, the patient's cognitive status is "Modified independence." She requires extensive assistance for bathing and lower body dressing. However, only limited assistance is needed for upper body dressing and toilet use. Supervision is needed for ambulation (uses a cane), locomotion and toilet transfer. She is continent of bowel and bladder. The patient is also independent with bed mobility and eating. There has had no significant change in her activities of daily living (ADL) status or self-sufficiency over the prior 90 days. Her condition and functional needs are not at a level or unpredictable as to require the requested 42 PCS hours/week. Based on the enclosed documents reviewed, the patient's health and safety is appropriately provided and maintained by the currently approved PCS, 22 hours/week.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations. All decisions are evidence-based.

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

The insurer's denial of coverage for the home care/personal care HHC(home health care) - level 2 personal care services, per 15 minutes increase to 42 hours per week is upheld. Medical necessity is not substantiated.