Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 66 Hour(s) per Week
The health plan denied: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 66 Hour(s) per Week
The determination is: Overturned

The patient is a female with medical history notable for arthritis, chronic pain, hypertension, and hypothyroidism. The patient is approved for 56 hours per week of level 2 personal care services. The patient and her care team requested an increase to 66 hours per week, and this request was denied by the health plan.

The request for additional hours states that the patient is home alone without supervision and is no longer able to get out of bed by herself. She needs assistance with feeding and all transfers. An office visit note was provided for review. It covers the patient's medical conditions. There is no discussion of functional status or personal care needs. Case manager care plan notes were also reviewed in detail.

A Uniform Assessment System (UAS) was completed and was available for review. The patient's cognition was noted to be impaired; she was alert and oriented to person and place only. She can make her needs known and recognizes caregivers. For her instrumental activities of daily living (IADLs), she requires maximal assistance for meal preparation, housework, shopping, and transportation. She requires extensive assistance for finances, medications, and phone use. For her activities of daily living (ADLs), she requires maximal assistance for bathing and dressing her lower body. She requires extensive assistance for hygiene, dressing her upper body, walking, locomotion, toilet transfer, and toilet use. She requires limited assistance for bed mobility and eating. She is occasionally incontinent of stool and urine. Compared to a prior assessment, her cognitive and functional performance did not change significantly. A task tool associated with the most recent assessment recommended 38.58 hours per week to address her personal care needs.

At issue is the medical necessity of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 66 Hour(s) per Week. The health plan's determination of medical necessity is overturned in whole. The requested health service/treatment of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 66 Hour(s) per Week is medically necessary for this patient.

The patient is of advanced age and has multiple functional limitations as outlined by the UAS. The patient's condition as described in the request (as essentially bed-bound) is more severe than described in the UAS; regardless of which reflects her true functional status, she requires at least extensive assistance or greater for nearly all ADLs, including toileting. Her personal care needs are expected to be continuous and unscheduled throughout the day. If her current needs are not being met, a modest increase in personal care hours to the requested 66 hours per week is medically appropriate and reasonable for the patient.