Appeal type: Medical necessity
Decision: Overturned

Diagnnosis: Osteoarthritis
Treatment: Home Health
The health plan denied the requested increase in personal care assistant hours as not medically necessary. 
The health plan's determination is overturned, in whole.

The patient is a female who is requesting an increase in home health services. According to the documentation provided, she is currently receiving 35 hours/week and is requesting an increase to 55 hours/week.
The patient is listed as having history of generalized osteoarthritis, coronary artery disease, hypertension, hyperlipidemia, diabetes, insomnia, mild intermittent asthma, chronic pain, urinary incontinence, gastroesophageal reflux disease (GERD), unsteadiness on her feet, unspecified dementia, anxiety and various nutritional deficiencies including vitamin B12, folate and vitamin D. In addition to some of the arthritic limitations, the patient is stated to have poor memory and bowel and bladder incontinence.
The Uniform Assessment System (UAS) assessment was reviewed. The patient is stated as needing help with shopping, cleaning, cooking and dressing. She lives with her adult son and daughter-in-law. The patient has language barriers. She uses a cane and a manual wheelchair. The patient is noted to have some impairment in memory, cognitive skills and decision-making ability. She is able to make her needs known and to direct care. The patient's ability to express her needs are usually understood. Comprehension is usually understood. General hearing is pretty good. There is some social withdrawal, some occasional mood symptoms including symptoms of anxiety and depression.
The patient is totally dependent for meal preparation. She is totally dependent for housework and requires maximal assistance with finances. She requires maximal assistance with medications, and extensive assistance with telephone use. She is totally dependent for shopping. Maximal assistance for transportation required. The patient requires extensive assistance with bathing, hygiene, dressing and walking, toilet use and transfer. She needs help setting up for meals, and otherwise eats independently.

At issue is the medical necessity for the requested health service/treatment of Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes increase to 55 hours per week.

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

Yes. The requested health service/treatment of Home Care/Personal Care HHC-Level 2 Personal Care Services, per 15 minutes Increase to 55 hours per week is medically necessary for this patient
According to the review between the 2 assessments, the patient has had some notable physical declines. She has developed total dependence in more areas of daily living. She also has had a general decline in her energy level and is demonstrating increased fatigue. Previously she was able to do tasks with some difficulty but completed them. She has not been able to complete multiple tasks as noted in the UAS.
Further, the task tool assesses her transfer needs at only being about 5 transfers a day. It is likely that this is largely underestimated. Multiple transfer events are anticipated to occur throughout the day including in and out of bed, on and off the toilet, up and down from chairs and up and down for meals. Each of these events likely requires a number of transfers in and of itself. It would not be hard to imagine at least 40 transfers a day. If each is assessed at taking 5 minutes, this would equate to over 3 hours a day and an additional 23 hours a week.
If other areas of her global functioning have declined as outlined, it would not be unreasonable to assess other areas that were deemed as unchanged as actually taking more time than previously determined.
As the patient was originally approved for 35 hours even an increase in 20 hours throughout the week for these various changes would equate to requested 55 hours.