Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, arthritis and sarcoidosis (lung). 
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 female with chronic medical problems including heart disease, arthritis and sarcoidosis (lung).  She lives in a 2-bedroom apartment with her son who is diagnosed with Down's syndrome (and has his own aides). The insurer approved home care / personal care Home Health Care (HHC) - level 2 personal care services, per 15 minutes 24 hour live-in. The patient requested home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift); which is currently under review. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is "minimally impaired." She is reportedly self-directing and able to make her needs known.  She is also able to activate her Personal Emergency Response System (PERS) is needed.  However, the clinical records document more significant cognitive deficits. The patient is reported as totally dependent for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She is also reportedly totally dependent for bathing, lower body dressing, toilet use and locomotion. Maximal assistance is reportedly needed for personal hygiene, upper body dressing, and bed mobility.  She reportedly needs extensive assistance for eating. The patient is reportedly frequently incontinent of bowel and bladder. She was more recently hospitalized for acute cystitis and urinary tract infection.  

The patient's functional ability and self-sufficiency have  reportedly declined and deteriorated, respectively over the prior 90 days. Her functional ability has also declined.  The patient's functional impairments are at a level or unpredictable as to require personal care services  (PCS) 24 hours/day (split shift). The clinical notes from her treating physician, hospitalization and personal care logs were reviewed. Of particular concern is the patient's limited mobility, risk of pressure ulcers, infection and falls. She requires routine repositioning in bed at least every 2-3 hours to decrease risk of ulcers, falls and infection. Based on the clinical records, a live-in personal care aide (PCA) is unlikely capable of obtaining approximately 5 hours of uninterrupted sleep over the course of a 24-hour shift. This physician would agree that attention to the patient's functional needs is more appropriately provided and maintained by the requested personal care services (PCS) 12 hours per day- 7 days per week (split shift) for a total of 168 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 24 hours per day (split shift) services is substantiated.