Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease
Treatment: Increase Home/Personal Care HHC level 2 Per 15 Minutes To 84 Hours Per Week
The insurer denied: Increase Home/Personal Care HHC level 2 Per 15 Minutes To 84 Hours Per Week
The denial is overturned.

The patient is an elderly female with a history of general debility due to Alzheimer's disease. The request is for Personal Care Assistance through Home Health care (Level 2) to be increased from 52 hours per week based on UAS (Uniform Assessment System) evaluation of 7 months ago, to 84 hours per week (12 hours per day, 7 days per week) based on UAS (Uniform Assessment System) evaluation of  4 months ago. The health plan denied coverage of the request, because the patient has no recent ER (emergency room) visits, hospitalizations, or changes in family or social circumstances. They also note that the currently approved hours meet her required needs for assistance with her ADLs (activities of daily living). The additional hours requested are because of the patient's chronic medical conditions, frequent falls, and increasing physical/cognitive decline and to help with her Activities of Daily Living (ADLs), as she is totally dependent and requires extensive assistance with dressing, bathing, grooming, transferring, turning, positioning, toileting, ambulation, meal preparation, eating, housekeeping and shopping. A review of the records showed that the patient has multiple chronic medical conditions including Alzheimer's disease, coronary heart disease, dementia, depression, hyperlipidemia, hypothyroidism, chronic pain, anemia, vitamin B12 deficiency, urinary/fecal incontinence, anxiety, mood disturbance, chronic kidney disease status post (s/p) left nephrectomy for kidney cancer. UAS (Uniform Assessment System) evaluation-NY evaluation of 4 months ago showed that she is moderately impaired cognitively with consistently poor or unsafe in making decisions, independent with bed mobility, required limited assistance with eating, extensive assistance with personal hygiene, upper body dressing, toilet transfer, walking, locomotion, phone use, maximal assistance for bathing, lower body dressing, toilet use/, stairs, transportation, managing medications, stairs, and total dependence for meal preparation, housework, managing finances, and shopping. The patient lives alone on the fifth floor of an apartment building with elevator access. The daughter-in-law comes in to help after her full-time work.

The requested Increase Home/Personal Care HHC level 2 Per 15 Minutes To 84 Hours Per Week is medically necessary.

The patient is moderately impaired cognitively. She is consistently poor or unsafe in decision making, and independent with bed mobility. She required limited assistance with eating, extensive assistance with personal hygiene, upper body dressing, toilet transfer, walking, locomotion, phone use, maximal assistance for bathing, lower body dressing, toilet use, stairs, transportation, managing medications, stairs, and total dependence for meal preparation, housework, managing finances, and shopping. The reason for denial by the health plan, as noted in the clinical information above, does not align with the patient's disability features as noted in the UAS (Uniform Assessment System) evaluation of 4 months ago. Therefore, the requested 84 hours per week (12 hours per day, 7 days per week) is medically necessary.