Diagnosis: Coronary artery disease, hypertension, hyperlipidemia, chronic renal failure, and osteoarthritis.

Treatment: Increase in personal care services, 24 hours a day, 7 days a week (split shift).

The insurer denied coverage for increase in personal care services, 24 hours a day, 7 days a week (split shift).

The denial is upheld.

According to the documentation submitted, this is a patient with a history of coronary artery disease, hypertension, hyperlipidemia, chronic renal failure, and osteoarthritis. According to the most recent Uniform Assessment System (UAS), the patient lives alone and is alert and oriented (A&O) x (times) 2, is able to direct care, is forgetful, sometimes disoriented, and the short-term memory is impaired. The patient is blind on the right eye, has diminished vision on the left eye, and requires total dependence for ordinary housework and locomotion. Maximal assistance is needed for meal preparation, managing medications, bathing, personal hygiene, dressing upper body, dressing lower body, walking, transfer toilet, and toilet use. No falls were reported in the last 90 days. The patient's physician is requesting an increase in personal care services to prevent further complications in the patient's health.

The records show no recent events. There were no falls, ER (emergency room) visits nor hospitalizations in the last 90 days. The Universal Assessment Comments describe no specific change in medical conditions. There was no report of the need to be fed frequently or any condition that would require turning, repositioning or frequent toileting. The Health Assessment report shows no new medical conditions, and the same level of support would be required. The patient is currently approved for 84 hours per week, 12 hours a day for 7 days per week. The physician letters of appeal describe medical conditions without specific change. Correspondence does not provide objective worsening to substantiate additional service.

Based on the above, 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 an increase in personal care services, 24 hours a day, 7 days a week (split shift) is not substantiated.