Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral vascular accident (CVA), colon cancer treatment, and visual loss
Treatment: Increase Home/Personal Care Level 2 to 64 Hours 
per Week
The insurer denied: Increase Home/Personal Care Level 2 to 64 Hours per Week
The denial is overturned.

The patient is an elderly female with a history of general debility. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 40 hours per week to 64 hours per week based on Uniform Assessment System (UAS) of 4 months ago. The health plan denied the request because the patient has enough hours allocated to meet her current needs including help with bed mobility, bathing, personal hygiene, upper/lower body dressing, walking, eating, meal preparation, housework, and medication management. The additional hours requested are because of the patient's chronic medical conditions, and to help with her activities of daily living (ADLs) with limitations from a previous cerebral vascular accident (CVA), colon cancer treatment, and visual loss from severe macular degeneration, as she requires extensive assistance with dressing, bathing, grooming, transferring, turning, positioning, toileting, ambulation, meal preparation, eating, housekeeping and shopping. A review of the records showed that the patient has multiple chronic medical conditions including colon cancer, cerebral vascular accident (CVA), severe macular degeneration with visual loss, carpal tunnel syndrome, peripheral neuropathy, coronary artery disease (CAD), congestive heart failure (CHF), gastroesophageal reflux disease (GERD), paroxysmal atrial fibrillation, pacemaker, amyloidosis, chronic anemia, severe generalized osteoarthritis, chronic venous insufficiency, and hypertension. Uniform Assessment System - New York (UAS-NY) evaluation of 4 months ago showed that the patient was minimally cognitively impaired, and supervision required in some recurring situations when her decisions are poor or unsafe, requires supervision with oversight or cueing for managing medications, phone use, bed mobility, eating, required limited assistance with managing finances, managing medications on some occasions, toilet use/transfer, extensive assistance with bathing, upper/lower body dressing, maximal assistance for transportation, and totally dependent for meal preparation, housework, and shopping. The patient lives alone in an apartment and has limited family support through her daughter whose husband is also being treated for cancer.

The requested health service is medically necessary.

The requested increase for personal care assistance through home health care (level 2) from 40 hours per week to 64 hours per week is medically necessary because based on the reviewed medical records, the patient has multiple medical conditions that make her severely disabled including limitations from previous cerebral vascular accident, colon cancer treatment, visual loss from severe macular degeneration, peripheral neuropathy, coronary artery disease (CAD), congestive heart failure (CHF), gastroesophageal reflux disease (GERD), paroxysmal atrial 
fibrillation, pacemaker, amyloidosis, chronic anemia, severe generalized osteoarthritis, chronic venous insufficiency, and hypertension. Also, the patient is minimally cognitively impaired and there are some recurring situations when her decisions are poor or unsafe, she requires supervision with oversight or cueing for managing medications, phone use, bed mobility, eating, 
requires limited assistance with managing finances, managing medications on some occasions, toilet use/transfer, extensive assistance with bathing, upper/lower body dressing, maximal assistance for transportation, and totally dependent for meal preparation, housework, and shopping. The patient lives alone in an apartment and has limited family support through her daughter whose husband is also being treated for cancer. The reason for denial by the health plan as stated in the clinical information above, does not align with the patient's disability including visual loss and difficulty in moving around, as stated above. Therefore, the 64 hours per week requested should be approved.