Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Disease, Diabetes

Treatment: Home care / personal care HHC (home health care) - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift)

The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift).

The denial is upheld. 

This is a patient with chronic medical problems including kidney disease, diabetes and anxiety.  The patient lives alone in a 1-bedroom apartment.  The patient is approved for home care / personal care home health care (HHC) - level 2 personal care services, per 15 minutes personal care assistance (PCA) (live-in).  The patient requested an increase; home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift) that was denied by the insurer, leading to an external review.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times."  The patient is reportedly total dependent to maximal assistance for performing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires maximal assistance for bathing and lower body dressing.  Extensive assistance is reportedly needed for personal hygiene, upper body dressing and toilet transfer/use.  Limited assistance is reportedly needed for bed mobility, locomotion and ambulation.  However, "Daughter reports history of wandering outside of their apartment but is usually brought back by security in the building or neighbors."  The patient is independent with eating.  The patient is frequently incontinent of bladder and occasionally incontinent of bowel.  There has been no reported change over the prior 90 days. There has been 1 reported fall over the prior 30 days.  The patient's functional ability has actually improved when compared to the UAS report.

This physician would agree that the patient may benefit from additional monitoring; particularly due to the patient's reported cognitive deficits and falls risk.  However, safety monitoring under PCS (personal care service) does not include monitoring an individual (e.g., [for example] wandering, falls risk) when no other Level I or Level II personal care services task is being provided.  The patient's clinical condition and functional deficits are not at a level and unpredictable as to require PCA (personal care aide) services 7 days per week, 24 hours per day (split shift).  Based on the clinical records, a live-in PCA is likely capable of consistently obtaining approximately 5 hours of uninterrupted sleep over the course of a 24-hour shift.   Based on the documents reviewed, the patient's functional needs are appropriately provided and maintained by the approved home care / personal care HHC - level 2 personal care services, per 15 minutes PCA (live-in).  

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).  

From a physical medicine and rehabilitation perspective, home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift) is not medically necessary.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift) is not substantiated.