Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiectasis
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 insurer denied: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 70 Hour(s) per Week 
The denial is: Overturned

The patient is a female with medical history notable for bronchiectasis now on the lung transplant list, Acute myeloid leukemia (AML) in remission, primary ciliary dyskinesia, and chronic respiratory failure with hypoxia and hypercapnia on oxygen, The patient is currently receiving Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week. Her care team requested an increase to 70 hours per week. This request was denied by the health plan.
Recent office visit notes from the patient's pulmonologist were provided for review. They state that the patient is now moving forward with the lung transplant process in the setting of benign cystic disease and bronchiectasis. There is no discussion of functional status.

A Uniform Assessment System (UAS) was completed and was available for review. A prior assessment was completed for comparison. The patient lives alone in her apartment. Cognition was intact. For her functional status for Instrumental activities of daily living (IADLs), she requires total dependence for housework. She requires maximal assistance for meal preparation. She requires extensive assistance for managing medications and finances. For her activities of daily living (ADLs), she requires extensive assistance for bathing, hygiene, dressing upper and lower body, walking, locomotion, toilet transfer, and toilet use. She is independent with bed mobility and eating. She is noted to require human assistance for walking (in addition to her walker) and transferring due to muscle weakness, shortness of breath, and pain. She is continent of stool and urine. When compared to the assessment from 2 months prior, she showed a decrease in functional capacity for hygiene, toilet use, toilet transfer, and locomotion. An associated tasking tool recommended 31 hours per week to cover her personal care needs.
The subject under review is the medical necessity for 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 is overturned.

The requested health service/treatment of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 70 Hour(s) per Week medically is necessary for this patient.
The Uniform Assessment System (UAS) demonstrates that over a short time period (less than 2 months), the patient has had a measurable decline in functional capacity. She was previously mostly dependent for IADL's but able to perform many ADL's. On the more recent assessment, she is requiring extensive assistance for nearly all ADL's. This includes assistance required for ambulating and toileting. The evaluation noted that previously the aide was able to leave meals for the patient to reheat on days the aide is not there. This may suffice for IADL's, but more hands-on assistance is required now that the patient needs more assistance with ADLs. She is able to use durable medical equipment (DME) to assist with some of these needs, but the UAS clearly states that she requires help from her aide in addition to the DME she has available. With this decline in function, it is reasonable that she would require an increase in CDPAS hours each week.