Appeal type: Medical necessity
Decision: Overturned

Orthopedic.
Home health care.

Diagnosis: mobility issues.
Treatment: Home Care / Personal Care Level 2 Personal Care Services: 70 Hours per Week.
The insurer denied Home Care / Personal Care Level 2 Personal Care Services: 70 Hours per Week.
The health plan's determination is overturned.

This is a female patient with a history of breast cancer, hypertension, coronary artery disease, diabetes mellitus type 2 with diabetic polyneuropathy, gastritis, a pulmonary nodule, dizziness, generalized muscle weakness, chronic fatigue, chronic pain due to cervical and lumbar degenerative disease and osteoarthritis of hips and knees, and urinary and fecal incontinence. She lives alone. The patient and her care team requested 70 hours of Personal Care Services per week.
A Uniform Assessment System (UAS) was completed. The patient was assessed at total dependence for tasks of meal preparation, ordinary housework, managing finances, shopping, transportation, and transfer toilet; maximal assistance with tasks of managing medications, bathing, personal hygiene, dressing upper and lower body, and toilet use; and extensive assistance with tasks of phone use, bed mobility, and eating. The tasks of walking and locomotion were not assessed. A tasking tool was used to determine that she requires 62.17 hours of aide service per week.
The patient's endocrinologist provided a letter of support stating that she would benefit from more help at home and recommended an increase in home health aide hours.
The patient's primary care physician (PCP) provided a letter. He states that she has had a cognitive, physical, and functional decline and requires assistance with activities of daily living, including cleaning, bathing, dressing, medication management, meal preparation, and performing falls. Her PCP states that increasing daily home care hours is medically necessary.
The patient's advocate provided a letter. Her advocate states she is wheelchair dependent and is not able to transfer from her bed to her wheelchair on her own. Her advocate states that she has severe hand tremors and needs to be fed. She states that the patient has urinary and fecal incontinence and is unable to change her diapers.
The health plan's determination of medical necessity is overturned as a whole.
Considering the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, 70 hours per week of personal care services are medically necessary.
There is documentation in the UAS of the patient requiring maximal assistance with the task of toilet use and total dependence on the task of transfer to the toilet. The patient's advocate states that the patient also requires assistance transferring to her wheelchair and locomotion. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time. The plan failed to document a plan to meet these unscheduled and unpredictable care needs. There is documentation from the patient's PCP of the medical necessity of increased Personal Care Services. The patient lives alone and does not have informal support for the entire time outside of the previously assigned Personal Care hours. Adaptive equipment and medical supplies cannot meet the patient's care needs. The requested increase in Personal Care Services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).