Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Incontinence
Treatment: Home Health Care ("HHC")- Personal Care HHC- Level 2 Personal Care Services, per 15-minutes to 84 hours per week
The insurer denied Home Health Care- Personal Care HHC- Level 2 Personal Care Services, per 15-minutes to 84 hours per week.
The determination is overturned.

This patient has a medical history notable for incontinence, heart failure, and coronary artery disease. The patient is approved for 42 hours per week of level 2 personal care services. The patient and his care team requested an increase to 84 hours per week.

The patient's physician provided a letter of medical necessity for this appeal. The letter states that the patient has had a functional decline since COVID. The patient is unable to stand or ambulate without assistance and depends on others for all activities of daily living. They have sustained multiple falls recently while attempting to ambulate independently. They cannot use the toilet without assistance. Their spouse recently died which worsened the patient's state and support within the home. The patient has been homebound and has had a functional decline.

A Uniform Assessment System (UAS) was completed earlier in the year and was available for review. The patient lives alone in an apartment building. The patient was alert and oriented to person and place only; they were forgetful and required cuing for procedural tasks. They are able to make needs known. For the patient's Instrumental activities of daily living (IADL), they require total dependence for housework. They require maximal assistance for meal preparation, shopping, and transportation. The patient requires extensive assistance for finances, medications, and phone use. For their activities of daily living (ADL) they require extensive assistance for bathing, dressing lower body, walking, and locomotion. The patient requires limited assistance for hygiene, dressing upper body, toilet transfer, and toilet use. They are able to walk a short distance with a walker and weight bearing support. The patient is infrequently incontinent of urine and continent of stool. Lastly, the patient had a fall the month prior when trying to get out of bed on their own. Compared with a prior assessment from the previous year, he showed a decline in both cognitive and functional status. At issue is the requested health service/treatment of Personal Care HHC - Level 2 Personal Care Services, per 15-minute increase to 84 hours per week.

The requested health service of Personal Care HHC-Level 2 Personal Care Services, per 15-minute to 84 hours per week is medically necessary for this patient.

The patient has had a decline in cognitive and functional status. They now require hands-on assistance for all Instrumental activities of daily living (IADL) and activities of daily living (ADL). They have suffered falls as a result of attempting to do transfers independently. Their current allotment is insufficient to meet their personal care needs; they cannot be left alone, unable to do transfers or toileting, for 18 hours per day. By increasing their personal care hours to 84 hours per week, they will have additional care during waking hours to help with meals, toileting, managing incontinence supplies, and other personal care tasks. It is medically necessary to provide for these personal care needs, and therefore the hours would not be spent purely for safety monitoring and supervision.