Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic uterine cancer, neuropathy, depressive disorder, hypertension, and hyperlipidemia
Treatment: Increase Home Care/ Personal Care HHC (home health care) Level 2 Personal Care Service Per 15 minutes to 84 Hours Per Week
The insurer denied:  Increase Home Care/ Personal Care HHC (home health care) Level 2 Personal Care Service Per 15 minutes to 84 Hours Per Week
The denial is overturned.

The patient is an elderly female. Her medical conditions including metastatic uterine cancer, neuropathy, depressive disorder, hypertension, and hyperlipidemia. Denial of increase personal care service to 84 hours per week is being appealed. The health plan approved 42 hours per week. Uniform Assessment System Evaluation (UAS) completed from 2 months ago shows independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping; extensive assistance with managing finances and medications, stairs, transportation, bathing, lower body dressing, walking, locomotion, and toileting; limited assistance with upper body dressing and personal hygiene; and independent with bed mobility and eating. Compared UAS (Uniform Assessment System) evaluation completed on 4 months ago, there has been a decline with housework, managing finances and medications, locomotion, walking, and toileting. A letter from the patient's provider notes that the patient has metastatic uterine cancer and is status post hysterectomy and had been chemotherapy. She may resume chemotherapy depending upon results of lung biopsy. The patient's physicians are anticipating worsening of her weakness. The patient's provider notes that the patient is dependent with all ADLs (activities of daily living). She uses a walker due to deconditioning and fatigue. A letter from another provider notes that the patient was diagnosed with uterine cancer and is status post hysterectomy. Lung biopsy is scheduled for this month. The patient is a fall risk due to poor balance. She uses a walker due to deconditioning and fatigue. Chemotherapy will make her more dependent.

The requested Increase Home Care/ Personal Care HHC (home health care) Level 2 Personal Care Service Per 15 minutes to 84 Hours Per Week is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase personal care service to 84 hours per week is being appealed. The health plan approved 42 hours per week. This patient has multiple chronic conditions, and a recent diagnosis of metastatic uterine cancer. Uniform Assessment System Evaluation (UAS) completed 2 months ago shows the patient requires assistance with all ADLs (activities of daily living), except bed mobility and eating. Compared UAS (Uniform Assessment System) evaluation completed 4 months ago, there has been a decline with housework, managing finances and medications, locomotion, walking, and toileting. Appeal statements note the patient has a decline in physical function related to chemotherapy and is dependent with ADLs (activities of daily living). She is anticipated to resume chemotherapy. This patient's physical functioning is significantly impaired. The amount of assistance needed with ADLs (activities of daily living) cannot be met with the approved personal care services at 42 hours per week. The requested increase in personal care services at 84 hours per week is medically necessary.