Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, hypothyroidism, seizures
Treatment: Increase Home/Personal Care HHC per 15 Minutes to 50 Hours per Week
The insurer denied: Increase Home/Personal Care HHC per 15 Minutes to 50 Hours per Week
The denial is overturned

The patient is an elderly female. Her conditions include osteoarthritis, hypothyroidism, seizures, pain, edema, and abnormal gait and mobility. Denial of increase home/personal care to 50 hours per week is being appealed. The health plan approved 28 hours per week.
Uniform Assessment System (UAS) evaluation completed on recently shows modified independent cognition and functional status: total dependence with meal preparation, housework, and shopping; extensive assistance with managing finances, transportation, bathing, and lower body dressing; limited assistance with upper body dressing, walking, locomotion, and toileting; set-up assistance with managing medications; and independent with personal hygiene, bed mobility, and eating. The patient uses a rollator for ambulation. She has frequent bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed on 2 years ago, there has been a decline with meal preparation, housework, shopping, transportation, bathing, dressing, walking, locomotion, and toilet use.
An appeal statement notes the patient was hospitalized recently for vertigo. She had a fall on at that time. She requires assistance to safely ambulate. In addition, she needs assistance with ADLs (activities of daily living).
Per a letter from the patient's provider, the patient is constantly presenting to the emergency room with trauma due to falls. Falls occur due to weakness and vertigo. The patient has no informal support.

The Increase Home/Personal Care HHC per 15 Minutes to 50 Hours per Week is 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. Denial of increase home/personal care to 50 hours per week is being appealed. The health plan approved 28 hours per week.
This patient has multiple chronic conditions and recent hospitalization for vertigo and falls. Uniform Assessment System (UAS) evaluation completed recently shows she requires assistance with all ADLs (activities of daily living), except personal hygiene, bed mobility, and eating. She has frequent bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed 2 years ago, there has been a decline with meal preparation, housework, shopping, transportation, bathing, dressing, walking, locomotion, and toilet use. Appeal statements support the patient's need for assistance with ADLs (activities of daily living). She has recurrent falls due to weakness and vertigo and needs assistance to assistance to safely ambulate. This patient's physical functioning is significantly impaired. Her level of functioning has deteriorated 
between UAS (Uniform Assessment System) evaluations. The need for assistance with ADLs (activities of daily living) cannot be met with the approved home/personal care to 28 hours per week hours per week. The requested increase home/personal care to 50 hours per week is medically necessary and appropriate.