Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ambulatory Dysfunction.
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Live In).
The insurer denied: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Live In).
The denial is: Overturn.

The patient is a male with a medical history notable for ambulatory dysfunction (wheelchair bound), memory impairment, incontinence, schizophrenia, and a history of stage 4 sacral ulcer (now healed). He has been in a skilled nursing facility for the past year following a hospitalization for myocardial infarction. He has been stable for discharge home if he can receive 24-hour care at home. The health plan approved discharge with home care for 10 hours per day and a reassessment after he has been discharged. This denial of 24-hour care is the subject of this review.

A Uniform Assessment System (UAS) was completed and was available for review. A prior evaluation was available for comparison. He was alert and oriented but forgetful with short-term memory. He can make his needs known and complete procedural tasks. For functional status, he requires total dependence on meal preparation and housework. He requires extensive assistance in managing medications and finances. He requires maximal assistance for shopping and transportation. For his activities of daily living (ADLs), he requires maximal assistance for bathing, dressing his lower body, locomotion, toilet transfer, and toilet use. He requires extensive assistance for hygiene, dressing his upper body, and bed mobility. He is wheelchair-bound and can walk a maximum of 40 feet with assistance. He needs one person to assist from laying supine to sitting. He is frequently incontinent of urine. He is occasionally incontinent of stool. The level of function was similar to the prior assessment.
The subject under review is the medical necessity for 24 hours per day (live-in) personal care services.

The health plan's determination is overturned. 

The requested health service/treatment of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hours (s) per Day (Live In) is medically necessary for this patient.
The health plan's recommendation to receive 10 hours of care per day and then reevaluate is not in the patient's best interest and would not allow for a safe discharge. He has demonstrated functional deficits that require around-the-clock care. He is not able to ambulate or use the bathroom without assistance. He has a history of stage 4 sacral ulcer (now healed) that would likely recur if he were to go 14 hours per day without any sort of assistance. This is also in violation of the safe discharge plan as recommended by the attending physician at the skilled nursing facility. Furthermore, he has daily episodes of urinary incontinence. If he does not receive proper incontinence care, he will likely suffer from skin breakdown (as has happened to him in the past) and/or infections. If the patient is to safely return to his apartment in the community, he will require the necessary support to do so.