Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple myeloma, deep vein thrombosis
Treatment: Consumer Directed Personal Assistance Services for a Total of Two 12 Hour (Split Shifts) for 7 Days
The insurer denied: Consumer Directed Personal Assistance Services for a Total of Two 12 Hour (Split Shifts) for 7 Days
The denial is overturned.

The patient is an adult female with a history of general debility and bed-bound while actively on chemotherapy for multiple myeloma, and unable to perform any activity of daily living (ADL). The request was for personal care assistance through home health care (level 2) to be increased from the previously approved 84 hours per week (7 days a week) from the Uniform Assessment System (UAS) evaluation of 4 months ago to two times 12-hour split shift services per day (7 days a week), for a total of 168 hours per week. The health plan denied the request because the patient has no nighttime needs, no medical need for frequent nighttime changing of incontinence products, no decubitus ulcers and she uses incontinence products. The additional hours requested are for the fact that the patient is totally dependent for her activities of daily living, completely bed bound, and uses a wheelchair, stretcher and Hoyer lift for mobility and transfer. A review of the records showed that the patient has multiple medical conditions including multiple myeloma with metastases, deep vein thrombosis (DVT) and on Eliquis, hypertension, gastro-esophageal reflux, esophagitis, etc. Uniform assessment system - New York (UAS-NY) evaluation of 2 months ago showed that the patient required total dependence with meal preparation, ordinary housework, using stairs, shopping, transportation, bathing, transfer, toileting, required extensive assistance with managing finances, managing medications, personal hygiene, bed mobility, requiring maximal assistance with upper body dressings, lower body dressings, etc. The patient needs to be moved every two to three hours as preventive measures against developing pressure ulcers as she is prone to developing infections as she is actively on chemotherapy.

The requested health service is medically necessary.

The requested increase for personal care assistance through home health care (level 2) from previously approved 84 hours per week (7 days a week) from the Uniform Assessment System (UAS) evaluation of 4 months ago to two times 12-hour split shift services per day (7 days a week), for a total of 168 hours per week is medically necessary because based on the most recent Uniform Assessment System - New York (UAS-NY) evaluation of 2 months ago the patient required total dependence with meal preparation, ordinary housework, using stairs, shopping, transportation, bathing, transfer, toileting, and required extensive assistance with managing finances, managing medications, personal hygiene, bed mobility, and required maximal assistance with upper body dressings, lower body dressings, etc. The patient needs to be moved every two to three hours as preventive measures against developing pressure ulcers as she is prone to developing infections as she actively on chemotherapy. The patient's total dependence for activities of daily living (ADLs) and with her need to be moved every two to three hours as preventive measures against developing pressure ulcers as she is prone to developing infections as she actively on chemotherapy, are good and tenable reasons for medical necessity. The reasons alluded by the health plan as reasons for denial do not reflect the findings in the Uniform Assessment System (UAS) report of 2 months ago. Therefore, the two times 12 hour split shift services per day (7 days a week) making a total of 168 hours per week should be approved.