Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Coronary artery disease (CAD), double bypass, hypertension, hyperlipidemia, hypothyroidism, and myocardial infarction (MI).
Treatment: Home care /personal care home health care (HHC) - level 2 personal care services, per 15 minutes increase to 84 hours per week.

The insurer denied coverage for home care /personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week.  The denial is overturned.

This patient has history of functional impairment affecting his ability to perform most daily activities. The patient now lives alone. He receives some informal help from his daughter, but mostly relies on personal care services (PCS) for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The insurer's final denial letter indicated patient had been receiving PCS 35 hours per week. A request for increase of PCS to 84 hours per week, was denied. However, on appeal, PCS was increased to 42 hours per week. 

The most recent Uniform Assessment System (UAS) report provided was reviewed. The functional status for IADLs, indicated patient is totally dependent for meal preparation, ordinary housework, shopping; he needs maximal assistance for transportation, managing finances, phone use, stairs; extensive assistance for managing medications. For ADLs, the patient needs maximal assistance for bathing; extensive assistance for personal hygiene, dressing upper and lower body, walking, locomotion, transfer toilet, toilet use; limited assistance for eating; setup help for bed mobility. 

The information provided indicates a significant change in the patient's family and home circumstances (death of his wife); decline in function for daily activities; and change is his support system. The patient was receiving PCS 10 hours per day as a mutual case with his wife at the time of prior UAS. The current UAS indicates the patient needs significantly more help with ADLs than previously, but he is actually receiving less services (6 hours per day) than when he was receiving mutual services with his wife (10 hours total per day). The patient has various health problems, functional impairment, and recently, emotional distress, all of which place significant burden on his ability to perform daily activities. 

Managed Long-term Care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. These care needs must be considered in the determination of the patient's personal care service hours.
 
It is medically necessary for the patient to have adequate caregiver assistance to ensure all daily activities are completed properly and safely; including all routine ADLs and IADLs; plus, ADLs that occur at unscheduled and recurring times of the day. Assistance is necessary to help prevent adverse health and safety events such as incontinence related skin damage, falls and household accidents, malnutrition, and dehydration. Assistance with mobility may also facilitate, if possible, activities outside the home that may help relieve feelings of isolation and depressed mood the patient has been experiencing recently.

The patient will benefit from PCS 12 hours per day, as he needs assistance with all daily activities, including all ADLs from the time he gets up in the morning until he goes to bed in the evening, and assistance with all meals. 

Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes, 84 hours per week is medically necessary. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for home care /personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week is overturned. Medical Necessity is substantiated.