Appeal type: Medical necessity
Decision: Overturned

Diagnosis: morbid obesity, hypertension, gout, renal osteo dystrophy, hyperlipidemia, osteoarthritis, renal disease, status post bilateral knee replacement, and low back pain with left-sided sciatica

Treatment: home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 60 hours per week

The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 60 hours per week

The denial is overturned.
 

This case involves an adult male with the subject of review being denial of home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 60 hours per week. 3 days/week (Monday, Wednesday, and Friday from 7:00 am to 11:00 am) and 4 days/week (no dialysis) (from 7:00 am to 7:00 pm) 48 hours.

Per the Uniform Assessment System, the member was alert and oriented x (times) 1, modified independence with cognition, does not have wandering episodes, no major stressors reported in the last 90 days, he is not lonely, requires maximal to extensive assistance with functional status, and his family is able to and willing to assist as needed after personal care services (PCS) hours. No hospitalizations or emergency room (ER) visits have been reported since the last assessment was completed. No hospitalization within 90 days. No pressure ulcer.

According to the recent Uniform Assessment System the member lives alone in an apartment with elevator access. He denies falling or hospital admissions in the last 3 months. He had an emergency visit due to increased shoulder pain after he was hit from behind by another car on the way home from a dialysis session. The member was cooperative, has a supportive family, and requires maximal to extensive assistance with functional status. He reports incontinence of bowel. He utilizes canes, commodes, pull-ups, shower chairs, and grab bars.

Due to limited endurance, weakness, fatigue, and the inability to stand and bear weight for prolonged periods of time, he requires assistance with personal care, assistance with dressing the lower and upper body, grooming, and bathing due to limited range of motion (ROM) and pain in multiple joints related to osteoarthritis (OA) and weakness after dialysis treatment. His daughter assists with financial management and medications. The member wears pull-ups due to occasional bowel incontinence. Skin is intact.

In the letter of reconsideration, it was noted that the member has had a noticeable difference in memory in the years since he started dialysis. According to the letter, he still has some denial about his memory problems.

In the medical necessity review, the request to qualify for home care and personal care HHC-level 2 personal care services per 15 minutes increased to 60 hours per week was denied. According to the assessment, there are no memory or cognitive changes. The member is bowel and bladder incontinent. The member filed an appeal as he is a dialysis patient, lives alone, and suffers from obesity, obstructive sleep apnea (OSA), hypertension, gout, renal osteodystrophy, hyperlipidemia, osteoarthritis, knee replacement, and sciatica. The patient needs help with all activities of daily living (ADLs). The patient's ADL status has declined, and his self-sufficiency has deteriorated. The patient needs 60 hours of home care services a week to meet his needs.


Based on the above,  there has been a deterioration in his function. This supports the requested increase. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 60 hours per week is  substantiated.