Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recent COVID infection, hypertension, coronary artery disease, atrial fibrillation, gastroesophageal reflux, cirrhosis, osteoarthritis, and edema
Treatment: Increase Home Health Care (HHC) Level II per 15 minutes to 40 hours/week
The insurer denied the increase in HHC level II per 15 minutes to 40 hours/week.
The denial is upheld.

This elderly female patient has conditions including recent COVID (Coronavirus) infection, hypertension, coronary artery disease, atrial fibrillation, gastroesophageal reflux, cirrhosis, osteoarthritis, and edema. She is appealing the denial of an increase in home health care (HHC) to 40 hours/week. The health plan approved 35 hours/week.

Uniform Assessment System (UAS) evaluation completed several months ago shows independent cognition and functional status: maximal assistance with housework and shopping; extensive assistance with meal preparation, stairs, and transportation; limited assistance with managing medications, bathing, lower body dressing, walking, locomotion, and toileting; set up with managing finances; and independent with personal hygiene, upper body dressing, bed mobility, and eating. She is continent. Compared to UAS evaluation completed last year, there has been a functional decline with toileting. 

A letter from the patient's physician endorses the patient was diagnosed with COVID one month ago and became more ill since that time. She has more memory loss, chest pain and worsening gout. She can no longer take care of herself. She is homebound and needs more help at home. A letter from the patient notes she lives alone. Her health has been declining the last 3 years. She uses a walker or walking stick at home. Her attendant helps with the wheelchair on the street. Her memory is declining, and she is forgetful. She has forgotten to turn the gas off after heating food.

The proposed treatment is not medically necessary. 

Personal assistance services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs), health maintenance activities, and routine support services. 

This patient has multiple chronic conditions, including recent COVID infection. She is appealing the denial of an increase in HHC to 40 hours/week. The health plan approved 35 hours/week. UAS evaluation completed 5 months ago shows independent cognition and need for assistance with housework, shopping, meal preparation, stairs, transportation, managing medications, bathing, lower body dressing, walking, locomotion, and toileting. She is continent. Compared to UAS evaluation completed last year, there has been a functional decline with toileting. Appeal statement notes a decline in the patient's functioning since COVID infection, including memory loss. However, there is no significant change in the patient's functioning between UAS evaluations. Personal care is not indicated for supervision or when no tasks are being performed. The information provided does not support a decline in the patient's functional needs that requires an increase in personal care hours. The approved personal care at 35 hours/week is appropriate to meet this patient's needs for assistance with ADLs. The proposed increase to 40 hours/week is not medically necessary.