Appeal type: Medical necessity
Decision: Overturned

Diagnosis: heart failure, diabetes, hypertension, kidney diseases on dialysis, glaucoma and peripheral vascular disease.
Treatment: Increase Home Care /Personal Care HHC Services Per 15 Minutes To 84 Hours Per Week.
The insurer denied the Increase Home Care /Personal Care HHC Services Per 15 Minutes To 84 Hours Per Week.
The denial is overturned.

The patient is a male with medical conditions including heart failure, diabetes, hypertension, kidney diseases on dialysis, glaucoma and peripheral vascular disease. He lives alone. Denial of increase personal care services to 84 hours per week is being appealed. The plan approved 56 hours per week.

Uniform Assessment System (UAS) evaluation performed shows minimally impaired cognition and functional status: total dependence with meal preparation and housework; maximal assistance with bathing, lower body dressing, walking, locomotion, and toileting; extensive assistance with managing finances and medications, personal hygiene, upper body dressing, and bed mobility; and supervision with eating. The patient uses a wheelchair and scooter for locomotion indoors. He has occasional bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in cognition and functional status with meal preparation, bathing, personal hygiene, lower body dressing, walking, locomotion, toileting, bed mobility and eating.

A letter from the patient's provider notes the patient had two serious falls while trying to get up from the bed. This occurred before health aide service hours. He has deterioration in functional level. He needs assistance with ADLs (activities of daily living) as accounted for in the UAS (Uniform Assessment System) evaluation. He frequently experiences dizziness while changing positions. His forgetfulness has advanced. A letter from another provider notes the patient has mobility issues and requires ambulette transportation with a lift. He had multiple falls at home recently due to instability and vision deterioration. He was hospitalized recently due to severe dizziness and vomiting.

Yes, the requested increase in personal care services to 84 hours/week is medically necessary.
This patient has multiple chronic conditions and is status post recent falls when transferring from bed without assistance. Denial of increase in personal care services to 84 hours per week is being appealed. The plan approved 56 hours per week. The plan did not increase hours based on the position that UAS (Uniform Assessment System) evaluation performed compared to previous assessment showed the ability to perform many daily activities remained the same.

UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living), except eating. He has bowel and bladder incontinence. He uses a wheelchair and scooter for locomotion indoors. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in cognition and functional status with meal preparation, bathing, personal hygiene, lower body dressing, walking, locomotion, toileting, bed mobility and eating. Appeal letters note the patient's cognitive and functional status has deteriorated. He has recent falls when the health aide is not present due to dizziness and instability with transfers. This patient has significant limitations with ADLs (activities of daily living) and personal care. Based on the deterioration in his functioning and degree of assistance needed, the approved 56 hours per week is inadequate to meet the patient's need for assistance with ADLs (activities of daily living) and personal care. The requested personal care services 84 hours per week is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.