Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metabolic encephalopathy, coronary artery disease and dementia. 
Treatment: Home Care/Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift). 
The insurer denied coverage for: Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift). 
The denial is overturned. 

This is an elderly patient with chronic medical problems including metabolic encephalopathy, coronary artery disease and dementia. The patient is currently receiving hospice care. The patient lives with their sister in a private residence. The insurer approved Home Care/ Personal Care home health care (HHC)- Level 2 PCS, per 15 minutes 1 day, per day (live-in). The request is for Home Care/ Personal Care HHC- Level 2 PCS, per 15 minutes increase to 24 hours per day (split shift); leading to an external review. 

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as severely impaired. The patient is total dependent for completing much of their Instrumental Activities of Living (IADL's) tasks including meal preparation, ordinary housework and shopping. The patient is also total dependent for bathing, personal hygiene, dressing, bed mobility (described as "bedbound"), locomotion, toilet transfer/use and is non-ambulatory. Maximal assistance is needed for eating. The patient uses portable oxygen. The patient has a foley catheter and is bowel incontinent. The patient's functional ability has declined when compared to a previous UAS report. 

The letters the patient's treating providers respectively describing her clinical condition and need for "around the clock care" were reviewed. Unfortunately, they did not include their associated treatment notes. However, the documents are sufficient to determine the patient's need for continuous custodial care. 

The patient does have cognitive and functional needs at a level or unpredictable as to require the requested Home Care/ Personal Care HHC- Level 2 PCS, per 15 minutes increase to 24 hours per day (split shift). Based on the clinical records, the approved live-in personal care services (PCS) is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep. The patient requires routine repositioning in bed, foley management and portable oxygen management. The patient is at significant risk for pressure ulcers, joint contractures, respiratory infections and urinary sepsis. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained at home with the requested Home Care/ Personal Care HHC- Level 2 PCS, per 15 minutes increase to 24 hours per day (split shift). 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, Home Care/ Personal Care HHC- Level 2 PCS, per 15 minutes increase to 24 hours per day (split shift) is medically necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not 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 24 hours per day (split shift) is substantiated.