Diagnosis: Diabetes, hypothyroidism and iron deficiency anemia
Treatment: Home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 50 hours per week
The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 50 hours per week
The denial is upheld

This is an adult with chronic medical problems including diabetes, hypothyroidism and iron deficiency anemia. She lives with her husband, daughter and son-in-law.

In the recent Uniform Assessment System (UAS) report the patient's cognition is described as moderately impaired. She reportedly requires extensive assistance to total dependence for much of her Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping. She reportedly requires extensive assistance for bathing, personal hygiene, dressing, locomotion, ambulation and toilet transfer/use. The patient is frequently incontinent of bowel and bladder. She is independent with bed mobility and limited assistance is needed for eating. The patient's functional ability is much the same; if not slightly improved compared to the prior UAS report.

The patient's condition and functional deficits are not at a level or unpredictable as to require an increase in personal care services from 45 to 50 hours/week. This physician would agree the patient may require additional monitoring, particularly due to her reported cognitive deficits. However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care service task is being provided. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the currently approved home care / personal care HHC - level 2 personal care services, per 15 minutes 45 hours per week.

From a physical medicine and rehabilitation perspective, the requested home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 50 hours per week is not medically necessary.

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 home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 50 hours per week is not substantiated.