Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease, Arthritis, Alzheimer's disease

Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, increase to 84 hours per week

The insurer denied coverage for Home Care / Personal Care HHC - Level 2 Personal Care Services, increase to 84 hours per week.

The denial is overturned. 

This is a male patient who has an extensive medical history and substantial functional impairment for daily activities. The patient lives with his son and daughter-in-law. He receives personal care services 70 hours per week as Consumer Directed Personal Assistance Services (CDPAS). His daughter-in-law is the CDPAS aide. A request was made to increase CDPAS to 84 hours per week.

According to Uniform Assessment System (UAS) documentation, the patient's functional status for Instrumental Activities of Daily Living (IADLs) included total dependence for all household related tasks, shopping, and finances; extensive assistance needed for all other IADLs. The patient needed extensive assistance with all Activities of Daily Living (ADLs) except eating (supervision). The patient has multiple medical conditions that may be contributing to his functional decline, including: chronic obstructive pulmonary disease (COPD)/asthma, chronic pain, and Alzheimer's disease. The patient needs extensive assistance for toilet transfer and toilet use. He is at high risk for falls, with risk factors including: arthritis, chronic pain, unsteady gait, cognitive impairment, incontinence, dizziness, and use of medication associated with falls.

Considering the patient's medical history, symptoms, and functional status noted in UAS documentation, and physician's letter, it is medically necessary for the patient to have assistance for all daily activities throughout the day. The patient needs assistance for daily activities that occur at various scheduled and unscheduled times throughout the day and night. This includes routine household tasks and other IADLs; routine morning and evening ADLs; meal preparation and assistance/supervision with meals; all toileting and incontinence related tasks; out-of-bed mobility. 

Considering the request is for CDPAS 84 hours per week (12 hours per day), it is reasonable to consider that these are the hours needed to accommodate most of the patient's daily care. The CDPAS hours can be utilized as 12 continuous hours morning through evening when patient is awake and most active; or possibly some hours can cover nighttime care. The patient lives with family; and so if the patient needs additional care periodically beyond 12 hours per day, then it appears this would be provided as informal caregiver assistance. 

Considering the patient's substantial daily care needs, and the presence of family living with the patient, then it appears CDPAS 84 hours per week, plus informal support (if care is needed beyond 84 hours per week) can meet the patient's need for assistance with ADLs and IADLs at this time.

Home Care/Personal Care HHC - Level 2 Personal Care Services 84 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the Home Care / Personal Care HHC - Level 2 Personal Care Services, increase to 84 hours per week is overturned. The medical necessity is substantiated.