Diagnosis: weakness/dizziness
Treatment: Home health care
The insurer denied Personal Care Assistance Services: Total of 45 Hours per Week. The health plan's determination is upheld.

This is a case review for a female with medical history notable for cerebellar ganglioglioma, chronic fatigue, dizziness, anxiety, depression, and gastritis. The patient and her care team requested Personal Care Assistance Services: Total of 45 Hours per Week. This denial is the subject under review.
The patient's physician provided a letter of support for this appeal. The patient suffers from long term sequelae of a cerebellar ganglioglioma resection including weakness and chronic dizziness. She has limited ability to climb, lift, and bend. She has chronic pain due to sciatica and scoliosis that occasionally flares. The letter states that she has two ventral hernias that need repaired but that the surgery has been postponed "due to the denial of augmented request of hours as she will need increased hours in the post-operative period." She has informal assistance from her spouse but he works 5am - 7:30pm daily. The physician requests additional hours to help with household cleaning, food preparation, shopping, and transportation to doctor's appointments.

The requested health service of Personal Care Assistance Services: Total of 45 Hours per Week has not been demonstrated to be medically necessary for this patient.
The patient has some functional limitations as outlined in the UAS. These revolve primarily around her instrumental activities of daily living. Her physician also requested the hours to assist primarily with Instrumental activities of daily living (IADL). The patient's current allotment of hours should be sufficient to assist with these tasks. She does not have any documented personal care needs that are not being met at her current level of hours. The patient has an upcoming surgery but increases in home health hours are not typically granted in anticipation of a future short term need. At the time of her surgery, her care may be more appropriately given in another setting. The patient is able to ambulate and toilet without a care aide. Therefore, she does not need continuous care throughout the day and additional hours beyond those recommended by the task tool. The increase in personal care assistance services has not been demonstrated to be medically necessary based on the documentation provided.