Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteoarthritis.
Treatment:  Home Care/Personal Care HHC (Health & Home Care) - Level 2 Personal Care Services: 56 Hours per Week.

The insurer denied Home Care/Personal Care HHC - Level 2 Personal Care Services: 56 Hours per Week.  The health plan's determination is overturned. 

The patient is a  male with past medical history of osteoarthritis, hypertension, chronic kidney disease with renal dialysis, benign prostatic hyperplasia (BPH), obstructive sleep apnea (OSA), diabetes mellitus type 2, hyperlipidemia, bladder incontinence, and venous ulcers who had been assigned personal care services (PCS). It is unclear from the medical records if the patient was hospitalized and then transferred to a Skilled Nursing Facility (SNF), but this appears to be the case, as notes from his assessment indicated that he was in SNF due to venous ulceration of both legs. While at SNF, there was a plan for him to be discharged and the patient underwent an assessment tool assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, stairs, and shopping. With tasks of transportation, bathing, dressing lower body, walking, locomotion, and transfer toilet the patient was assessed at extensive assistance, while limited assistance with tasks of personal hygiene and dressing upper body. The patient was assessed at set up only with tasks of managing finances and manage medication while independent with tasks of toilet use, bed mobility, eating, and phone use. Notes from the  assessment stated the patient had no informal help.

Home Care/Personal Care HHC - Level 2 Personal Care Services: 56 Hours per Week are medically necessary for this patient.

The patient had a stay at SNF related to venous ulcers with request to increase PCS. The patient's assessment tool noted the patient needs at least extensive assistance with walking, locomotion, and transfer toilet which are unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient has chronic kidney disease with renal dialysis and the tasking tool did not calculate hours for transportation to and from dialysis and medical appointments. The requested increase in PCS is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The plan noted on its denial decision that the patient had no change between assessments but only one assessment was completed and was noted to be the initial assessment for the patient. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care/Personal Care HHC - Level 2 Personal Care Services: 56 Hours per Week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.