Diagnosis: Shoulder bursitis, labral hip tears, and depression
Treatment: Home health care (HHC) level 2 personal care services (PCS), per 15 minutes increase to 45 hours/week, consumer directed personal assistance services (CDPAS)
The insurer denied coverage for HHC level 2 PCS, per 15 minutes increase to 45 hours/week, CDPAS.
The denial is upheld.

This is an adult female with diagnoses of shoulder bursitis, hip labral tear, and depression. She lives with and cares for her 3 children in a private residence. The patient requested an increase in home health care (HHC) level 2 personal care services (PCS), per 15 minutes increase from 30 to 45 hours/week, denied by the insurer and currently under external review.

The Uniform Assessment System (UAS) report describes the patient's cognitive skills as "Modified independent." She is self-directing, fully oriented and has a Personal Emergency Response System (PERS). Her ability to perform instrumental activities of daily living (IADLs) including meal preparation, ordinary housework and shopping varies from total dependence to independent. The patient also independently drives a motor vehicle including driving her children to school. She reportedly requires limited assistance for bathing and lower body dressing. The patient is otherwise independent for personal hygiene, upper body dressing, eating, bed mobility, locomotion, toilet transfer/use, and ambulation. She reports frequent bladder incontinence and is continent of bowel. There have been no reported falls over the prior 90 days.

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the requested HHC level 2 PCS, per 15 minutes increase to 45 hours/week, consumer directed personal assistance services (CDPAS). Her functional ability has actually improved when compared to the prior UAS report. The patient is essentially functionally independent and any residual functional needs can be appropriately provided and maintained via the more than adequate approved HHC level 2 PCS, per 15 minutes 30 hours/week, CDPAS.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The medical necessity for HHC level 2 PCS, per 15 minutes increase to 45 hours/week, CDPAS is not substantiated.