Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Benign paroxysmal positional vertigo (BPPV)
Treatment: Personal Care Services to 10 hours a day, 7 days a week, at total of 70 hours per week (following Discharge from skilled nursing facility (SNF))
The insurer denied the coverage.
The health plan's determination is overturned.

The patient is a female with a medical history of obesity, arthritis and other orthopedic diagnoses affecting mobility, cervical spine disease, chronic kidney disease, spinal stenosis, and venous insufficiency. The patient was receiving 30 hours per week of personal care services. She is being discharged from a skilled nursing facility and has requested an increase in personal care hours to 70 hours per week (10 hours per day, 7 days per week).
A letter of medical necessity was provided by the patient's treating physician from the skilled nursing facility. The letter states that the patient has multiple medical problems and requires many medications to help with these issues. Common side effects of these medications include lightheadedness, dizziness and low blood pressure. For this reason, she requires a great deal of assistance with activities of daily living (ADL's) due to additional unsteadiness on her feet. The patient lives alone and has no other formal or informal help. The physician feels that an increase is "medically necessary in order to meet all the patient's personal care needs."
A letter of support for this appeal was provided by a patient advocate. The letter states that the patient is declining in performing her ADL's due to a recent addition of vertigo to her medical problems. The advocate states that the patient needs 10 hours per day of help to cover assistance with unscheduled ambulation, transferring and toileting. 

A letter of support for this appeal was provided by the patient's primary care physician of the past 5 years. The letter states that the patient's current aide hours are insufficient to meet her personal care needs and describes this situation as unsafe if she does not have an increase in hours.
A letter from the patient's primary care office states that "in order for her to be safely discharged home she requires the assistance of a home health aide" for the requested duration.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was found to be independent in decision making and her memory was intact. From a functional standpoint, she requires total dependence for housework. The patient requires maximal assistance for meal preparation, managing medications, shopping and transportation. For her ADL's, she requires extensive assistance for bathing, dressing lower body, walking, locomotion and toilet transfer. She requires limited assistance for hygiene, dressing upper body, and toilet use. The patient is independent for bed mobility and eating. She ambulates with a quad cane and gets "extremely dizzy and is unable to stand or walk for a long period of time." The patient is infrequently incontinent of urine and continent of stool. An algorithm that translates functional impairments (HELPS assessment) associated with the UAS recommended 32 hours of personal care assistance per week. Compared with a prior UAS, her functional status has declined in most domains.

The patient requires assistance for multiple ADL's and Instrumental activities of daily living (IADL's) as demonstrated by the notes and the UAS. The associated tasking tool recommended a minimum of 32 hours of personal care services for week to address these needs. She is currently approved for 30 hours. The tasking tool can be helpful as a guideline for minimum times needed to cover the patient's needs; however, it is not unusual for this to be inadequate due to the unscheduled nature of many personal care needs. There is demonstrated medical necessity for an increase in personal care assistance hours as requested by the patient and her care team.