Central Nervous System/Neuromuscular
Home Health Services

Diagnosis: Memory Decline
Treatment: 7 hours per day, 7 days per week, total of 49 hours per week- personal care services, level 2
The insurer denied 7 hours per day, 7 days per week, total of 49 hours per week- personal care services, level 2.
The determination is upheld.


This is a male patient with a medical history notable for memory decline and depression. The patient was approved for 5 hours per day, 7 days per week (35 hours per week) of level 2 personal care services. The patient and his care team requested an increase to 7 hours per day, 7 days per week (49 hours per week) and this request was denied by the health plan.
The patient's optometrist provided a letter of support for this appeal. The letter states that the patient is being treated for glaucoma.
The patient's physician provided a letter of support for this appeal. The letter states that the patient is not able to ambulate to the bathroom without assistance and is "almost totally dependent" for help with activities of daily living.
The patient's psychiatrist provided a letter of support for this appeal. The letter states that the patient has severe depression and panic disorder. He has fears of going out alone and of being alone in the house.
A Uniform Assessment System (UAS) was completed and was available for review. Compared to a prior UAS, he showed a slight functional decline. A task tool associated with the most recent assessment recommended 33.1 hours per week to address his personal care needs, which was an increase from the 27.4 hours recommended on prior assessment. At issue is the medical necessity of 7 hours per day, 7 days per week, total of 49 hours per week- personal care services, level 2.

The requested health service/treatment of 7 hours per day, 7 days per week, total of 49 hours per week- personal care services, level 2 has not been demonstrated to be medically necessary for this patient.
The patient requires assistance with several personal care tasks as outlined in the letters from his treatment team and from the UAS. The letters do not describe any currently unmet personal care needs that could be adequately met with an additional two hours per day. The request for additional hours to address his anxiety and failure to keep appointments is not a level 2 personal care function. He does require assistance for IADLs and ADLs, but he is receiving 35 hours per week which is greater than the 33 hours per week recommended by the task tool. There is no clearly demonstrated personal care need that is not being met at his current allotment of hours that would be met with the additional hours requested.