Diagnosis: Asthma, pain, arthritis, hypertension.
Treatment: Personal Care Services, Level II.
The insurer denied: Personal Care Services, Level II.
The denial is upheld.

This adult female patient has asthma, anxiety, depression, allergic rhinitis, hyperlipidemia, arthritis, and hypertension. She is appealing the denial of level II personal care services. The request was denied because the patient's Uniform Assessment System evaluation performed 4 months ago showed no need for assistance with activities of daily living (ADLs) and personal care. The Uniform Assessment System (UAS) evaluation completed last year shows independent cognition and independent functioning, except total dependence with housework. There is a letter that notes the denial of services "hinders progress/maintaining/improving cognitive function". The patient has hearing loss, anxiety, and panic attacks. She takes several medications. She has occasional body weakness and fatigue.

The proposed treatment is 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 level II personal care services. The request was denied because Uniform Assessment System evaluation performed 4 months ago showed no need for assistance with activities of daily living (ADLs) and personal care. Uniform Assessment System (UAS) evaluation completed last year shows independent cognition and independent functioning, except total dependence with housework. The appeal statement does not support the patient's need for assistance with activities of daily living (ADLs). Personal care services are not indicated when no tasks are being performed. The proposed personal care services are not medically necessary.