Appeal type: Medical necessity
Decision: Overturned

Diagnosis: diabetes, hypertension, renal failure on dialysis, anxiety, depression, urinary incontinence and shoulder pain
Treatment: Increase Home Care/Personal Care HHC Level 2 Personal Care Services per 15 Minutes From 56 Hours per week To 24 Hours Per Day (live in)
The insurer denied the Increase Home Care/Personal Care HHC Level 2 Personal Care Services per 15 Minutes From 56 Hours per week To 24 Hours Per Day (live in)
The denial is overturned

The patient is a male. His conditions include diabetes, hypertension, renal failure on dialysis, anxiety, depression, urinary incontinence and shoulder pain. He was hospitalized with urosepsis. Denial of increase in home care/personal care (PCA) from 56 hours per week to 24 hours per day, live in, is being appealed.

Uniform Assessment System (UAS) evaluation completed shows the patient has minimally impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, stairs, transportation, bathing, dressing, walking, locomotion, and toileting; extensive assistance with phone use, personal hygiene, and bed mobility; and limited assistance with eating. The patient has generalized weakness and ambulates with a walker. He has frequent bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline with dressing and eating.

An appeal letter from the patient's provider notes the patient's condition has deteriorated. He has limited range of motioned pain. He awakens five to six times at night to urinate. He has a history of multiple falls in the last several months. It notes that the patient should not stay alone.

Yes, the requested increase in personal care assistance to 24 hours/day, live-in, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase in home care/personal care (PCA) from 56 hours/week to 24 hours per day, live in, is being appealed.

The patient has several chronic conditions. The patient has recent hospitalizations for urosepsis and after a fall. Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). He has frequent bladder incontinence. Comparison to UAS (Uniform Assessment System) evaluations completed previously there has been a decline with dressing and eating. The appeal letter from his doctor notes the patient's condition has deteriorated. The patient has limited range of motion and frequent falls. The patient awakens five to six times at night to urinate. This patient has significant physical impairments that have progressed between UAS (Uniform Assessment System) evaluations. His limitations include transfers for toileting. Based on the frequency of need for toileting through the night, the approved PCA (Personal Care Assistance) 56 hours per week is inadequate to meet the patient's needs for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living). The requested increase in PCA (personal care assistance) to 24 hours per day, live-in, is medically necessary.