Appeal type: Medical necessity
Decision: Overturned

Diagnosis: CHF (congestive heart failure), Diabetes Mellitus, dizziness, unsteady gait, general weakness and history of multiple falls
Treatment: Increase Home/Personal Care HHC Level 2 per
15 Minutes to 70 Hours per Week
The insurer denied: Increase Home/Personal Care HHC Level 2 per 15 Minutes to 70 Hours per Week
The denial is overturned.

The member is an elderly female with history of arthritis with general debility. The request was for Personal Care Assistance through Home Health care (Level 2) to be increased from 42 hours per week to 70 hours per week. The health plan denied the request because she has no loss of motion and her ability to perform physical functioning are adequate for bed mobility, bathing, personal hygiene, upper/lower body dressing, walking, feeding, meal preparation, ordinary housework and medication management, while she has no memory issues and has urinary incontinence but no bowel incontinence. The additional hours requested are for safety monitoring and stated to be beyond the amount, curation and scope needed to meet her personal care needs. A review of the records showed that member has multiple medical conditions including CHF (congestive heart failure), Diabetes Mellitus, dizziness, unsteady gait, general weakness and history of multiple falls associated with limited range of motion, severe impaired mobility, ambulating with walker with one person assist along with cognitive impairment, all likely to 
place her at serious risk of injury and the reason why she "needs assistance around the clock." UAS (Uniform Assessment System)-NY evaluation of six months ago showed that she required extensive assistance with walking (requiring weight-bearing support with 1 helper lifting limbs), locomotion, transfer toilet, toilet use and dressing lower body. The functional limitations were in completing IADLS (instrumental activities of daily living) because of her osteoarthritis, scoliosis, history of fall, anxiety and other co-morbidities mentioned above. She is alert and oriented x 2 with tendency to forget things. Her family support is very limited as the son lives out of state.

The proposed treatment is medically necessary.

The requested increase for Personal Care Assistance through Home Health care (Level 2) from 42 hours per week to 70 hours per week is medically necessary because based on the most. 
recent UAS (Uniform Assessment System) from six months ago in which she required extensive assistance with walking (requiring weight-bearing support with 1 helper lifting limbs), 
locomotion, transfer toilet, toilet use and dressing lower body. The functional limitations were in completing IADLS (instrumental activities of daily living) because of her osteoarthritis, scoliosis, history of fall, anxiety and other co-morbidities mentioned above. 
She is alert and oriented x 2 with tendency to forget things. 
Her forgetfulness, and extensive limitations in mobility coupled with her increased tendency to falls are good and tenable reasons for the medical necessity. The reasons alluded by the health plan as reasons for denial do not reflect the finding in the UAS (Uniform Assessment System) report of six months ago. 
Therefore the 70 hours per week requested should be approved.