Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus type two (DM2), hypertension (HTN), benign prostatic hypertrophy (BPH), urinary incontinence, and end stage renal disease (ESRD)
Treatment: Level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift)
The insurer denied coverage for Level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift).
The denial is overturned

The patient has a medical diagnoses of diabetes mellitus type two (DM2), hypertension (HTN), benign prostatic hypertrophy (BPH), urinary incontinence, and end stage renal disease (ESRD). The patient is currently on treatment with dialysis three times a week. The patient has had multiple falls in the last six months, due to generalized pain and weakness. The patient urinates multiple times at night and needs help changing diapers. An increase in personal care services from 24 hours per day (live-in) to split shift is requested. The treating provider prescribed level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift). The treating provider is requesting plan approval for treatment with Level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift).

Per the patient, the current helper is working 13 hours. The patient needs assistance at night. 

Level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift) is considered medically necessary for this patient.

The patient has generalized weakness and a history of multiple falls. The patient needs help 24 hours a day, 7 days a week, day and night. Per the patient, the current helper is working 13 hours. The patient urinates multiple times at night and needs help changing diapers. The patient needs assistance at night and the help requested is reasonable. 

"Home health care is a system of care provided by skilled practitioners to patients in their homes under the direction of a physician. Home health care services include nursing care; physical, occupational, and speech-language therapy; and medical social services. (1) The goals of home health care services are to help individuals to improve function and live with greater independence; to promote the client's optimal level of well-being; and to assist the patient to remain at home, avoiding hospitalization or admission to long-term care institutions. Physicians may refer patients for home health care services, or the services may be requested by family members or patients." (Ellenbecker, et al., 2008).

"The results accentuate the importance to patients of participating in their own care, especially in the selection of HC (home care) assistants. The model illustrates some challenging areas for improvement within the organization of 24-hour home care, such as personnel continuity and competence, collaboration, and routines for acute care. Furthermore, it may be used as a basis for reflection during the planning of care for individual patients within home care." (Swedberg, et al., 2012).  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the Level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift) is overturned. Medical Necessity is substantiated.