Diagnosis: Memory Issues
Treatment: Home care/personal care HHC (home health care)- level 2 personal care services, per 15 minutes increase to 50 hours per week
The insurer denied home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 50 hours per week
The determination is upheld.

This is a female patient with a medical history notable for poor memory and incontinence. The patient is approved for 30 hours per week of level 2 personal care services. The patient and her care team requested an increase to 50 hours per week, and this request was denied by the health plan. There were no letters of medical necessity or medical records provided as part of this review. The member's care plan notes were provided and reviewed in detail.

A Uniform Assessment System (UAS) was completed and was available for review. The patient lives with her husband in a private home. Her Consumer Directed Personal Care Assistance Services (CDPAS) caregiver is her daughter. The patient is a mutual case with her husband. The patient was recently discharged home from a skilled nursing facility after a planned hospitalization for a knee replacement. The patient's cognition was minimally impaired; she was alert and oriented to person and place only, but able to direct her own care. For her instrumental activities of daily living (IADLs), she requires total dependence for meal preparation and housework. She requires maximal assistance for finances, stairs, shopping, and transportation. For her activities of daily living (ADLs), she requires maximal assistance for bathing and dressing lower body. She requires extensive assistance for hygiene, dressing upper body, toilet transfer, and toilet use. She requires limited assistance for walking, locomotion, bed mobility, and eating. She ambulates with a walker with a slow and unsteady gait. She needs extensive assistance with transferring including toileting. She is frequently incontinent of urine and uses pullups for incontinence care. Compared with a UAS (prior to the knee surgery), the patient's functional status improved modestly. A task tool associated with the most recent UAS recommended 35 hours per week to address her personal care needs, a decrease from the 43 hours recommended on prior assessment. At issue is the medical necessity of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 50 hours per week.

The requested health service/treatment of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 50 hours per week has not been demonstrated to be medically necessary for this patient.

The patient has functional limitations as outlined in the UAS. She showed improvement over earlier this year after receiving knee replacement surgery, which is expected to improve the patient's mobility. The patient appears to have adequate formal and informal support. There is no documentation regarding what personal care needs, if any, are not being met at the current allotment of CDPAS hours.