Diagnosis: Dizziness and giddiness, hypertension, weakness, pain, tremor, diabetes, and chronic pain.
Treatment: Increase Home Health Care (HHC)/Personal Care Level II Per 15 Minutes to 49 Hour(s) per Week.

The insurer denied: Increase Home Health Care (HHC)/Personal Care Level II Per 15 Minutes to 49 Hour(s) per Week.

The denial is overturned.

This elderly female patient has medical conditions including dizziness and giddiness, hypertension, weakness, pain, tremor, diabetes, and chronic pain. She is appealing denial of increase home care/personal care to 49 hours per week. The health plan approved 35 hours per week.

Uniform Assessment System (UAS) evaluation completed recently shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing medications, stairs, transportation, and lower body dressing; limited assistance with managing finances, phone use, personal hygiene, upper body dressing, walking, locomotion, and toileting; and independent with bed mobility and eating. She has frequent bladder incontinence. Compared to Uniform Assessment System (UAS) evaluation completed 3 years prior, there has been a decline with meal preparation, walking, and locomotion.

The proposed treatment is 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 care/personal care to 49 hours per week. The request was denied based on the Uniform Assessment System (UAS) evaluations showing minimally decreased functioning to now needing limited assistance with locomotion, walking, and phone use. Her activities of daily living have not changed overall. The health plan approved 35 hours per week. Uniform Assessment System (UAS) evaluation completed recently shows the patient requires assistance with all activities of daily living, except bed mobility and eating. Compared to Uniform Assessment System (UAS) evaluation completed 3 years prior, there has been a decline with meal preparation, walking, and locomotion. The patient has significant impairment in daily functioning. Uniform Assessment System (UAS) evaluations show the patient's functional status has declined. The approved personal care at 35 hours per week is insufficient to meet the patient's needs for assistance with activities of daily living (ADLs) and personal care.

The proposed personal care of 49 hours per week is medically necessary.