Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mitral valve regurgitation, cardiomyopathy, hypercalcemia, hyperlipidemia, osteoporosis, anemia, malnutrition, CAD (coronary artery disease), hypertension, emphysema, asthma
Treatment: Increase personal care services, 24 hours a day, 7 days a week (split-shift)
The insurer denied Increase personal care services, 24 hours a day, 7 days a week (split-shift).
The denial is overturned.

The patient is an adult female with a history of general debility due to chronic medical conditions. The request is for Personal Care Assistance through Home Health Care (Level 2) to be increased from 49 hours per week to 168 hours per week (24 hours per day, 7 days per week), based on UAS (Uniform Assessment System) evaluation of 3 months ago. The health plan denied the request, noting that the patient's needs are expected to improve in the near future. The partial increase allowed is expected to give her enough support for current ADLs (activities of daily living), including personal hygiene, upper body dressing, walking, locomotion, toilet transfer, toilet use, bathing, and lower body dressing. The additional hours requested are because of the patient's chronic medical conditions with declining status, and to help with her Activities of Daily Living (ADLs) such as preparing meals, housekeeping, laundry, shopping, transferring, bathing, dressing, toileting, medication reminders, personal hygiene, eating, etc. Help aids do not help with managing medical conditions. She is also unsteady on her feet with a history of falls. A review of the records showed that the patient has multiple chronic medical conditions including Mitral valve regurgitation, cardiomyopathy, hypercalcemia, hyperlipidemia, osteoporosis, anemia, malnutrition, CAD (coronary artery disease), hypertension, emphysema, asthma, etc. UAS (Uniform Assessment System) evaluation of 2 months ago showed that the patient was moderately cognitively impaired with decisions consistently poor or unsafe with supervision required at all times, required limited assistance with phone use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, toilet use, extensive assistance with personal hygiene, upper body dressing, locomotion, toilet transfer, toileting, bed mobility, eating, phone use, walking, maximal assistance for bathing, lower body dressing, meal preparation, housework, managing finances, managing medications, stairs, shopping, transportation, equipment management, etc. She lives alone in a 1-bedroom apartment.

The requested Increase personal care services, 24 hours a day, 7 days a week (split-shift) is medically necessary.

Based on the most recent UAS (Uniform Assessment System) evaluation of 3 months ago, the patient was moderately cognitively impaired, with decisions consistently poor or unsafe with supervision required at all times, required limited assistance with phone use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, toilet use, extensive assistance with personal hygiene, upper body dressing, locomotion, toilet transfer, toileting, bed mobility, eating, phone use, walking, maximal assistance for bathing, lower body dressing, meal preparation, housework, managing finances, managing medications, stairs, shopping, transportation, equipment management, etc. The reason for denial by the health plan as noted in the clinical information above, does not align with her disability features as noted in the UAS (Uniform Assessment System) evaluation of 3 months ago as stated above.
Therefore, based on the UAS (Uniform Assessment System) evaluation of 3 months ago, the requested increase in personal care service to 168 hours per week (24 hours per day, 7 days per week) is medically necessary.