Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mobility Issues.
Treatment: Level 2 Personal Care Services, per 15 minutes increase to 70 hours.
The insurer denied Level 2 Personal Care Services, per 15 minutes increase to 70 hours.
The determination is overturned.

This is a female patient with a medical history notable for chronic pain, mobility issues, and incontinence. The patient is approved for 60 hours per week of personal care services at home. The patient and her care team requested an increase to 70 hours per week, and this request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The letter states that the patient's ability to walk is deteriorating due to chronic low back pain. She has been working with a pain management specialist and has still had worsening of her symptoms. She had a recent fall when ambulating without assistance and sustained a head injury. The patient is on chronic anticoagulation with warfarin and is at risk for severe injury with falls. She has frequent seizures, at times as often as every one to two days. The letter states that the patient requires having her home health care aide present additional hours so that she can prepare the patient for sleep at night and for waking up in the morning. Specifically, she needs help with transferring to the bed, bathing, and dressing. She is often awake and, in a urine, -soaked diaper waiting for her aide to arrive in the morning. The additional hours would allow her to have prompt personal care.

A Uniform Assessment System (UAS) was completed. The patient lives alone in her apartment. She is alert and oriented with some periods of forgetfulness noted. For her instrumental activities of daily living, she requires total dependence on meal preparation, housework, and shopping. She requires maximal assistance for transportation and stairs. For her activities of daily living, she requires maximal assistance for bathing, hygiene, dressing, and toilet use. She requires extensive assistance for walking, locomotion, and toilet transfer. She requires limited assistance for bed mobility and eating. She is frequently incontinent of urine and occasionally incontinent of stool. She wears diapers for incontinence care. There was no pressure ulcer present at the time of evaluation. Compared to a prior assessment, the patient showed a decline in functional status. At issue is the medical necessity of Level 2 Personal Care Services, per 15 minutes increase to 70 hours.

The requested health service of Level 2 Personal Care Services, per 15 minutes increase to 70 hours per week is medically necessary for this patient.
The patient requires personal care assistance for all activities of daily living including incontinence care, toileting, transfers, and bathing. Her physician letters provide evidence of unmet personal care needs. She needs additional time to allow for prompting for medication administration, diapering after episodes of incontinence, and transfers into and out of bed. Therefore, the requested increase to 70 hours per week is medically necessary and reasonable for the patient. Her current allotment of hours has been insufficient to meet her needs.