Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Home Health Care
The insurer denied an increase in personal care services for medical necessity. 
The denial was overturned. 

The patient is a female who resides alone and suffers from age-related physical disabilities and cognitive impairment due to vascular dementia showing signs of progressive memory loss, as well as adjustment disorder with anxiety and depression related to the recent passing of her husband. She has chronic pain and difficulty with ambulation, standing, and weightbearing with significantly impaired coordination, motor function, and limited range of motion as well as reduced mobility secondary to her chronic pain. She is unable to walk independently without personal assistance and the use of a walker due to post stroke ataxia, monoplegia, and foot drop of the right lower extremity. In addition, the patient suffers from hypertension, congestive heart failure, coronary artery disease, hyperlipidemia, cerebrovascular disease, type 2 diabetes with secondary neurologic, circulatory, and visual complications, obesity, osteoporosis, deconditioning, insomnia, venous insufficiency, urinary incontinence, and fecal incontinence.

According to a note from her physician, she has had rapid cognitive, physical, and functional decline in addition to some sensory impairments. According to this, she requires continuous supervision and assistance. She is no longer able to independently perform activities of daily living such as cooking, cleaning, bathing, dressing, grocery shopping, lifting, or maintaining her household. She requires daily assistance with reminders, preparation and administration of medications and meals. She requires assistance with self-care, household chores, shopping, transportation, and doctor's appointments. Additionally, due to her mobility issues, she requires human assistance with transfers, toileting, hygiene, and fall prevention. The recommendation was for 12 hours of home care daily, 7 days a week to maintain the patient's current health and prevent further decline. These recommendations were denied by the patient's health plan as they recommended no change in her current level of care/assistance of 48 hours (hrs) per week.

An increase in services is requested due to declining ability to perform multiple tasks.

At issue is an increase in personal care services, 12 hours a day, 7 days a week, for a total of 84 hours for medical necessity.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of personal care services, 12 hours a day, 7 days a week, for a total of 84 hours is medically necessary for this patient.

Due to the patient's advanced age and advancing medical conditions, her current level of home health care is inadequate and insufficient. Many of her limitations cannot be managed in a 6 to 7-hour window alone. According to the records provided, she goes through at least 10 adult diapers a day. The patient has chronic urinary incontinence and occasional fecal incontinence. She has difficulty with ambulation, mobility and toileting as well as changing her depends. With her chronic pain and reduced mobility, effective and safe access and use of the toilet independently is not to be expected. This places the patient at an increased and unnecessary risk for skin breakdown, infection, falls, and subsequent morbidity and mortality.

Therefore, the service of personal care services, 12 hours a day, 7 days a week, for a total of 84 hours is medically necessary.