Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal - Mobility issues.
Treatment: Home Health Care.
The insurer denied Home Care/Personal Care HHC-Level 2 Person Care Services, per 15-minute increase to 84 hours per week.
The denial is overturned. 

This is a case of a female with a past medical history of diabetes, morbid obesity, cardiac disease, cognitive impairment due to dementia, incontinence, lumbar radiculopathy, spinal stenosis, arthritis, and associated mobility issues. The health plan authorized 4 hours per day, 7 days per week of in-home personal care services. Subject to a fair hearing, an increase to 10 hours per day, 7 days per week was granted until the hearing. The patient's son and advocacy team are requesting a permanent authorization to increase to 12 hours per day 7 days per week for her care needs.
Support for this appeal was provided with a letter from the patient's treating neurosurgeon. This note states that she is not a candidate for surgical treatment and has had progressive decline in function and mental status. There is also a letter from a pain management specialist, who noted that the patient is "totally disabled, severe over weighted, limited ability to walk, needs assistance in everyday activity...she requires extended homestay care." The patient's son and attorney provided letters.
A Uniform Assessment System (UAS) community health assessment was performed. Two prior assessments performed were available for comparison. She lives by herself and has no informal helpers. The review showed some forgetfulness and short-term memory decline, and that in specific recurring situations her decisions become poor and unsafe. For her functional status, she was noted to have total dependence for meal preparation and ordinary housework. She requires extensive assistance for managing medications and finances. She requires maximal assistance for toilet transfer, bathing and dressing the lower body. She requires extensive assistance for personal hygiene, dressing upper body, walking, locomotion, and toilet use. She requires limited assistance for bed mobility. She is occasionally incontinent of urine (less than daily). She is infrequently incontinent of stool. Nearly all of these aspects of functional status have declined since the prior evaluation. She wears Pull-ups for incontinence episodes but is not able to change them herself. Skin was intact with no pressure ulcer.
At issue is the medical necessity of Home Care/Personal Care HHC-Level 2 Person Care Services, per 15-minute increase to 84 hours per week.

The health plan's determination of medical necessity is overturned, in whole.

Yes, the requested health service/treatment of Home Care/Personal Care HHC-Level 2 Person Care Services, per 15-minute increase to 84 hours per week is medically necessary for this patient.

The patient's UAS have shown a clear pattern of functional (as well as now cognitive) decline, and this decline in function is not expected to improve. She already requires extensive assistance for ambulation and toileting. Although the UAS states that there is no change in activities of daily living (ADL) status or overall self-sufficiency compared to the prior assessment, this statement is in direct contradiction to the functional assistance requirements outlined in prior sections of the document. Given her needs for assistance with ambulation, toileting, and hygiene, combined with her complex medication regimen with medication dosing required at various times throughout the day, it is reasonable that she would require 12 hours of personal care services daily. She has also started to experience continence issues, although they are infrequent, they are unpredictable in nature and could lead to further unscheduled hygienic assistance needs.
Therefore, the requested health service treatment of Home Care/Personal Care HHC-Level 2 Person Care Services, per 15-minute increase to 84 hours per week is medically necessary.