Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Generalized osteoarthritis, hypertension, diabetes mellitus, Sjogren's disease, breast cancer status post mastectomy, bladder cancer status post cystectomy with urostomy, anxiety, depression, incontinence of bladder/bowel, history of falls, chronic pain syndrome, and coronary artery disease (CAD)
Treatment: Increase Home/Personal Care Level 2 Services to 36 Hours Per Week
The insurer denied: Increase Home/Personal Care Level 2 Services to 36 Hours Per Week
The denial is overturned.

The patient is an elderly female with a history of general debility due to general osteoarthritis. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 24 hours per week based on Uniform Assessment System (UAS) of 3 months ago to 36 hours per week based on Uniform Assessment System of 2 months ago. The health plan denied coverage of the request, because she has poor memory, no loss of motor function, and the currently authorized hours are adequate in the amount, duration, and scope necessary to 
meet her personal care needs. The additional hours requested are because of the patient's chronic medical conditions, and to 
help with her activities of daily living (ADLs), as she requires extensive assistance with dressing, bathing, grooming, transferring, turning, positioning, toileting, ambulation, meal preparation, eating, housekeeping, and shopping. She is also at high risk of falls. A review of the records showed that the patient has multiple chronic medical conditions, including generalized osteoarthritis, hypertension, diabetes mellitus, Sjogren's disease, breast cancer status post mastectomy, bladder cancer status post cystectomy with urostomy, anxiety, depression, incontinence of bladder/bowel, history of falls, chronic pain syndrome, and coronary artery disease (CAD). The patient's Uniform Assessment System (UAS) evaluation of 2 months ago showed that she is minimally cognitively impaired and in specific recurring situations, decisions become poor or unsafe; requires set up/independent for phone use and eating; requires limited assistance with bed mobility and eating; requires extensive assistance with managing medications, stairs, bathing, personal hygiene, upper body dressing, low body dressing, walking, locomotion, toilet transfer/use; requires maximal assistance for managing finances and transportation; and is totally dependent for meal preparation, housework, shopping, etc. She lives with her elderly spouse in a two-bedroom apartment on the first floor.

The requested Increase Home/Personal Care Level 2 Services to 36 Hours Per Week is medically necessary.

The patient is minimally cognitively impaired, and in specific recurring situations, decisions become poor or unsafe; she required set up/independent for phone use and eating; required limited assistance with bed mobility and eating; required extensive assistance with managing medications, stairs, bathing, personal hygiene, upper body dressing, low body dressing, walking, locomotion, toilet transfer/use; required maximal assistance for managing finances, transportation; and was totally dependent for meal preparation, housework, shopping, etc. The 
reason for denial by the health plan as stated in the clinical information above, does not align with her disability features as stated in the Uniform Assessment System of 2 months ago as stated above. Therefore, the 36 hours per week requested is medically necessary.