Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied HHC-Level 2 Personal Care Services per 15 minutes increase to 70 hours per week. 
The health plan's determination is overturned in whole.

The patient is a female with past medical history of Alzheimer's disease, malignant hypertension, coronary artery disease, atrial fibrillation, mitral valve insufficiency, chronic systolic heart failure, multiple falls, unsteady gait, low back pain, multi-joint osteoarthritis, bilateral rotator cuff tendonitis, anemia, chronic edema, urinary incontinence, anxiety, and depression who had been assigned 56 hours/week home care/personal care home health care (HHC) services based on assessment tool. At this assessment the patient was assessed at total assistance with task of ordinary housework and maximum assistance with tasks of meal preparation, stairs, shopping, transportation, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, personal hygiene, dressing upper body, transfer toilet, and toilet use while limited assistance with tasks of walking, locomotion, and bed mobility. The patient was assessed at set up only for task of phone use and was independent with task of eating. The assessment notes noted the patient did not have informal helper and would not use commode or toilet when PCA not available due to her difficulty with transferring and walking.

The subject under review is the medical necessity for the Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes increase to 70 hours per week.

The health plan's determination is overturned in whole.

The requested home care/personal care HHC-Level 2 Personal Care Services per 15 minutes increase to 70 hours per week is medically necessary for this patient.

The patient has documented progressive medical illnesses of Alzheimer's dementia and osteoarthritis as well as multiple cardiac diagnoses who had been assigned personal care services of 56 hours per week based on an assessment tool performed at the beginning of the year. The patient was noted to have a change in functional status with a request for increased hours and another assessment tool performed in the summary via the telephone with increased need for assistance with tasks of walking and locomotion. There was a decrease in assistance needs for tasks of bed mobility and transportation, as it is documented by the assessor that the patient's overall self-sufficiency has decreased and is unable to walk on her own. The plan failed to take into account the patient's unscheduled and unpredictable care needs. The patient has urinary incontinence and is unable to use toilet, transfer toilet and perform incontinence cares on her own. It is stated in the most recent assessment that the patient has an informal helper, which is an uncertainty, as this is contradictory in the medical records provided. The request for increase in personal care service hours is not solely for safety and supervision but to assure safe completion of one or more of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient's medical provider provided documentation of medical necessity of increased personal care service hours in a letter. Personal care services are medically necessary when assistance and nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.