Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Home Care/Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 70 Hour(s) per Week.

The health plan denied: Home Care/Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 70 Hour(s) per Week.
The determination is: Overturned

The patient is a female with a medical history notable for uterine cancer, heart disease, cognitive impairment, incontinence, and heart failure. The patient is approved for 42 hours per week of personal care services. The patient and her care team requested an increase to 70 hours per week.
The patient's daughter provided a letter of support for this appeal, stating that the patient's current hours are insufficient to meet her needs. She cannot walk on her own and requires assistance. Because she is only receiving 6 hours per day, the rest of the day she is remaining sedentary and is not able to move around at all. She also requires assistance with transfers to the toilet. She has diapers for incontinence, which require unscheduled changing.
The patient's physician also provided a letter of support for this appeal. The letter states that the patient suffers from poor gait and mobility due to severe osteoarthritis. She requires assistance for walking, toileting, meal preparation, bathing, dressing, and grooming.
Daily care logs for the patient were provided for review. The logs demonstrate that the patient requires assistance with personal care tasks from the time that she wakes up until she goes to bed. There are no significant gaps of unused time in the personal care logs.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives at home with her spouse and son. Her son serves as her consumer directed care aide. This is a mutual case with her spouse. The patient was alert and oriented to person in place only with forgetfulness noted. For her instrumental activities of daily living, she requires total dependence for meal preparation, housework, and shopping. She requires maximal assistance for transportation and extensive assistance for finances, medications, and phone use. For her activities of daily living, she requires maximal assistance for bathing, dressing her lower body, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, and bed mobility. While she is continent of stool, she is frequently incontinent of urine and uses diapers for incontinence care. A task tool associated with the assessment recommended 50 hours per week to address the patient's personal care needs. The UAS was repeated and did not show any decrease in the patient's level of function and, in fact, this assessment suggested a slightly higher level of functioning on activities of daily living. The updated task tool associated with the new assessment recommended 29.5 hours per week to address her personal care needs.
At issue is the medical necessity of Home Care/Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 70 Hour(s) per Week.
The health plan's determination of medical necessity is overturned in whole.
The requested health service of Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 70 Hour(s) per Week is medically necessary for this patient.
The patient's assessment demonstrates that she requires hands-on assistance for all activities of daily living. Her personal care needs are expected to be continuous and unscheduled throughout the day. The daily care logs provided by the personal care assistant corroborate this. Therefore, the requested increase in personal care hours is medically necessary and reasonable for the patient.