Diagnosis: Osteoarthritis, hypertension, heart failure, type 2 diabetes, hyperlipidemia, hypokalemia, fatigue

Treatment: Level 2 Personal Care Services, per 15 minutes increase to 42 hour(s) per week of consumer directed personal assistance services (CDPAS)

The insurer denied coverage for Level 2 Personal Care Services, per 15 minutes increase to 42 hour(s) per week of consumer directed personal assistance services (CDPAS)

The denial is upheld.

This is a patient with diagnoses of primary generalized osteoarthritis, hypertension, heart failure, type 2 diabetes, hyperlipidemia, hypokalemia, fatigue, gait and mobility abnormality, pain, and vitamin D (calciferol) deficiency. The patient had a recent fall with a decline in his functional abilities. The most recent Uniform Assessment System (UAS) submitted indicates that the patient lives with spouse, can activate emergency plan, can make phone calls and is continent of bladder and bowels.

The health care plan partially approves the increase in the patient's personal assistance services. It was determined that an increase from 28 hours per week to 32 hours per week was medically necessary based on a decline in his ability to perform a range of functional tasks including bathing, dressing, walking, using the toilet, managing medications, preparing meals, and doing housework and shopping. The request for an increase to 42 hours per week was denied. This decision was based on the plan's Tasking Tool (which provided standard recommended personal care hours based on the member's functional needs). It was noted that although the member did not have any recent emergency room (ER) visits, hospitalizations, or changes in family or social circumstances, the member did have a recent fall with a decline in his functional abilities. This decision by the health care plan is reasonable and medically sound based on the patient's functional status and the Tasking Tool.

The provided documentation does not support the medical necessity for Level 2 Personal Care Services, per 15 minutes increase to 42 hours per week of consumer directed personal assistance services (CDPAS) for this patient. There is no evidence to support an increase in the patient's personal care services from 28 hours per week to 42 hours per week. The clinical documentation does not support an increase in personal care services to 42 per week as medically necessary. The appeal by the Attending Physician does not include any clinical information to support an increase to in personal care services to 42 hours per week. The Tasking Tool is a reasonable approach to determine the appropriate number of personal care hours based on the member's functional needs.

The insurer's denial must be upheld.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for Level 2 Personal Care Services, per 15 minutes increase to 42-hour(s) per week of consumer directed personal assistance services (CDPAS) services is not substantiated.