Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD), coronary heart disease. 
Treatment: Home care / personal care HHC (home healthcare) - level 2 personal care services, per 15 minutes increase to 84 hours per week. 
The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week. 
The denial is overturned. 
 
This elderly patient has extensive medical history associated with functional impairment and needs help with all daily activities. The patient lives alone. As per Uniform Assessment System (UAS), there are no informal helpers. The patient receives personal care services (PCS) 49 hours per week to assist with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Current personal care service (PCS) schedule is 8 AM - 3 PM. The patient reported he needs more help after 3 PM. The patient requested (via designee) increase of PCS to 84 hours per week, which was denied. 

The most recent UAS provided was reviewed. The functional status report for IADLs indicated patient is totally dependent for ordinary housework, meal preparation, stairs, transportation; he needs maximal assistance for shopping; setup help for phone use, managing finances; supervision for managing medications. For ADLs, the patient needs maximal assistance for bathing, dressing lower body, walking, locomotion, transfer toilet, toilet use; extensive assistance for bed mobility, dressing upper body; limited assistance for personal hygiene; supervision for eating. 

The patient has limited use of his right arm. It was reported that a fall caused fracture of his right arm (location of the fracture is not noted). UAS reports patient has a slight contracture of right arm. The records also report right shoulder rotator cuff tear (it is not clear if this is related to the fall that caused right arm fracture). The UAS and physician's letter indicate loss of right upper extremity function (as per physician, this is patient's dominant side). 

The patient has chronic obstructive pulmonary disease (COPD) (no medical records are available regarding history and current pulmonary function). The prior UAS reported no dyspnea; and no medication for COPD was noted. The recent UAS reported dyspnea with exertion, and the patient uses Spiriva. This suggests some changes in the patient's respiratory function occurred and he now needs daily treatment. The UAS reports patient has decreased endurance, and fatigue to the extent that he is unable to finish usual daily activities. These symptoms are associated with COPD as disease progresses. The patient also has cardiac disease including angina and ischemic cardiomyopathy; medications include valsartan, metoprolol, ranolazine, clopidogrel. Cardiovascular disease is a significant cause of functional decline in older people and can contribute to fatigue, decreased endurance and low activity tolerance. 

Recommendation is given to approve Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes, 84 hours per week. 

Based on the above, the insurer's denial must be overturned. 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 84 hours per week is substantiated.