Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, hypertension and sarcoidosis of the lung.

Treatment: home care/personal care HHC - Level 2, personal care services, per 15 minutes increase to 70 hours per week.

The insurer denied coverage for home care/personal care HHC - Level 2, personal care services, per 15 minutes increase to 70 hours per week.

The denial is overturned.

 
This elderly patient has extensive medical history associated with functional impairment and needs assistance with all daily activities. The patient lives at home with her son (he is disabled). As per the Uniform Assessment System (UAS), family has provided some informal help (patient has other children who do not live with her; disabled son is not able to provide care to patient). The patient primarily depends on assistance from personal care aides, including personal care services (PCS) which was providing 35 hours per week. In addition, the UAS reported the patient was also receiving private aide services 6 hours x 6 days per week (current private aide hours are not specifically reported in the available records). The patient's daughter (as patient designee) requested an increase of PCS to 70 hours per week, which was denied; but the insurer increased PCS to 40 hours per week. 

The patient's physical functional status is significantly impaired due to multiple contributing factors:

The patient has chronic pain from various causes. Diagnoses reported in the medical records include lumbar spondylosis, lumbar stenosis, radiculopathy, cervical stenosis, and osteoarthritis (noted as multiple sites, including knees). 

Lower back and knee pain can cause significant limitation of function for all mobility (walking, transfers, stairs) and several ADLs (activities of daily living) (e.g., lower body dressing, bathing, toileting). Lumbar and cervical stenosis can cause weakness in the lower extremities which can further limit the patient's mobility.

The patient has upper extremity weakness (3/5); cause is not noted. It may be due to generalized weakness from deconditioning; another possibility is cervical stenosis which can cause upper extremity weakness. The UAS also reported shoulder pain. Several activities are affected by upper extremity pain and weakness, e.g., upper body dressing, bathing, personal hygiene, toileting, eating, and most household tasks.

There are significant adverse consequences and risks associated with the patient's functional impairment.

Considering the patient's medical history and functional impairments, it is medically necessary for the patient to have a caregiver present for a more extended period of time each day. The patient needs assistance for IADLs (instrumental activities of daily living) and ADLs that occur at various scheduled and unscheduled times throughout the day. This includes household tasks; assistance with medications; preparation/service of all 3 meals with assistance for positioning in chair and with eating; routine morning and evening ADLs (bathing, dressing, personal hygiene); and unscheduled, recurring activities, including toileting/incontinence care; mobility around the home (transfers, walking); and repositioning for pressure and pain relief. Without adequate assistance, the patient is at risk for adverse health and safety events, e.g., skin damage due to incontinence and pressure; nutritional decline, dehydration; falls/injuries; and inadequate pain control.

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(Home Health Care) - Level 2, personal care services, per 15 minutes increase to 70 hours per week services is substantiated.