Appeal type: Medical necessity
Decision: Upheld

Diagnosis: OA (osteoarthritis), COPD (chronic obstructive pulmonary disease), GERD (gastroesophageal reflux disease), history of breast cancer, history of COVID, and CAD (coronary artery disease)
Treatment: Increase in Home Care/Personal Care HHC Level II, Per 15 Minutes, to 56 Hours per Week
The insurer denied the increase in home care/personal care HHC level II, per 15 minutes, to 56 hours per week.
The denial is upheld.

The patient is a female. Her medical conditions include OA (osteoarthritis), COPD (chronic obstructive pulmonary disease), GERD (gastroesophageal reflux disease), history of breast cancer, history of COVID, and CAD (coronary artery disease). Denial of increase in home care/personal care HHC (home health care) to 56 hours per week is being appealed. The health plan approved an increase from 20 to 28 hours per week.

UAS (Uniform Assessment System) evaluation completed shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation and shopping; extensive assistance with managing medications and finances, bathing, and lower body dressing; limited assistance with personal hygiene, upper body dressing, locomotion, walking, and toilet transfer; supervision with toilet use; and independent with bed mobility and eating. The patient does not have incontinence. Compared to UAS evaluation on completed previously, there has been a decline in functional status with ability to perform housework, bathing, personal hygiene, upper body dressing, walking, locomotion, and toileting. The patient was hospitalized for DVT (deep venous thrombosis) for approximately 2 weeks, transferred to rehab and discharged to home.

No, the increase in home care/personal care HHC level II, per 15 minutes, to 56 hours per week 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. Denial of increase in home care/personal care HHC (home health care) to 56 hours per week is being appealed. The health plan approved an increase from 20 to 28 hours per week.

This patient has multiple chronic medical conditions and was hospitalized due to DVT (deep venous thrombosis). UAS (Uniform Assessment System) evaluation completed shows the patient requires extensive or more assistance with housework, meal preparation shopping, managing medications and finances, bathing, and lower body dressing. She requires limited assistance with personal hygiene, upper body dressing, locomotion, walking, and toilet transfer. She does not require assistance with toilet use, bed mobility, or eating. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with ability to perform housework, bathing, personal hygiene, upper body dressing, walking, locomotion, and toileting. She does not have incontinence. There has been deterioration in the patient's functional status between UAS (Uniform Assessment System) evaluations. The increase in hours from 20 to 28 hours per week is sufficient to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. Personal care hours are not indicated for supervision or when no services are being performed. The proposed increase in personal care hours to total 56 per week is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.