Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Cognitive Decline, Mobility Issues, Major Depression, Anxiety, Hypertensive Heart Disease, Ataxia, Repeated Falls

Treatment: Home Care / Personal Care, home health care (HHC) - Level 2 Personal Care Services, per 15 Minute Increase to 56 Hours per Week

The insurer denied the Home Care / Personal Care, home health care (HHC) - Level 2 Personal Care Services, per 15 Minute Increase to 56 Hours per Week.

The health plan's determination is overturned.

The patient is a female with a past medical history of hypertension, hyperlipidemia, angina, congestive heart failure, permanent pacemaker, anxiety, depression, urinary incontinence and bilateral carpal tunnel syndrome. She also has a medical history of osteoarthritis, spinal stenosis of the lumbar and cervical region, diabetic neuropathy, osteoporosis, fecal incontinence, gastroesophageal reflux disease (GERD), diabetes mellitus type 2, and breast cancer. She had been assigned consumer directed personal assistance program (CDPAP) services for 28 hours/week based on an assessment performed via video. At this assessment the patient was assessed at maximum assistance with tasks of ordinary housework and shopping while extensive assistance was needed with tasks of meal preparation, stairs, transportation, bathing, dressing lower body, and toilet use. With the tasks of personal hygiene, dressing upper body, walking, locomotion, and toilet transfers the patient was assessed at limited assistance while supervision was needed with the task of managing finances. The patient was assessed at set up only with the task of managing medication and independent with the tasks of phone use, bed mobility, and eating. The tasking tool estimated 29 hours/week.

There was a request to increase CDPAP services and the patient underwent another video assessment assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with the tasks of managing finances, managing medication, stairs, transportation, dressing lower body, walking, locomotion, toilet transfers and toilet use while limited assistance was needed with the tasks of bathing and dressing upper body. With the task of phone use the patient was assessed at set up help only and independent with tasks of personal hygiene, bed mobility, and eating. Notes from the assessment stated the patient lived in a 2 bedroom apartment, had a decline in decision making capacity, had a decline in her functional status, and had deterioration in overall self-sufficiency. The assessment also stated the patient had 4 falls in the last 90 days and the tasking tool estimated 33.67 hours of care needs per week.

There is documentation from the patient's healthcare advocate and medical provider of worsening cognitive and physical functioning. The tasking tool estimated 33 hours/week based on an assessment that was performed and 29 hours based on a prior assessment. Despite an increase in care needs with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, bathing, personal hygiene, walking, locomotion, and toilet transfers. The patient requires extensive assistance with walking, locomotion, toilet transfers, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient would require assistance outside of the hours she does not have informal support.

The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.

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