Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma/ Injuries/Other/History of falls. 
Treatment: Home Health Care/Denial of Personal Care Services. 

The health plan had denied the requested treatment, Personal Care Services, as not medically necessary. The health plan's determination is overturned. 

This is a case review for a female with a medical history notable for falls, incontinence, arthritis, weakness, memory loss, and atrial fibrillation on Warfarin. The patient is approved for 6 hours per day, 6 days per week and 5.5 hours per day, 1 day per week (41.5 hours per week) of Personal Care Services (PCS). The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week). 

The patient's physician provided a letter which states that the patient's current home health hours are insufficient to meet all of her needs. The patient is homebound and has limited mobility. She has chronic diarrhea as a side effect of her medications and requires assistance with toileting. She also requires help with bathing, dressing, grooming, transfers, and ambulation. The patient is at risk for falls and fell after attempting to toilet when an aide was not available. She lives alone and has no informal support. Her functional capacity has declined significantly following a fall with femur fracture earlier this year. She is also at high risk with falls because of anticoagulation for atrial fibrillation. The patient's podiatrist provided a letter which states that the patient has issues with dynamic balance, peripheral neuropathy, and weakness. As such, the physician requests a one person assist for all activities. The director of social services at the patient's short term rehabilitation facility provided a letter which states that the patient would like to go home, but she lives alone. She requires a one-person assist with all activities of daily living including transfers, ambulation, and toileting. 

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in a rehabilitation facility after her fall and surgery for her left hip. The patient was alert and oriented but forgetful. She was able to direct her own care and ask for help in an emergency. For her instrumental activities of daily living (IADL's), she requires total dependence for housework. She requires maximal assistance for meal preparation, stairs, shopping, and transportation. She requires extensive assistance for finances and medications. For her activities of daily living (ADL's), she requires maximal assistance for bathing and dressing her lower body. She requires extensive assistance for hygiene, dressing her upper body, locomotion, toilet transfer, toilet use, and bed mobility. She requires limited assistance for walking and eating. She had difficulty walking and was mostly in a wheelchair which was propelled by others. She requires an aide to transfer to the toilet. She is frequently incontinent of urine and occasionally incontinent of stool. She requires diapers and pullups for incontinence care and requires assistance from aides for changing. 

At issue is the medical necessity for PCS in the amount of 12 hours per day, 7 days per week. 

The health plan's determination of medical necessity is overturned, in whole. 

The requested health service of PCS in the amount of 12 hours per day, 7 days per week is medically necessary for this patient. 

The patient requires hands on assistance for essentially all ADL's and IADL's. She requires help with toileting, transfers, and walking. She is frequently incontinent and requires assistance with changing incontinence products. Her personal care needs are expected to be continuous and unscheduled throughout the day. Her fall when attempting to toilet independently is evidence of unmet personal care needs. The requested increase to 12 hours per day is medically necessary and reasonable for the patient.