Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Post-polio syndrome, intracranial hemorrhage, metastatic small cell lung cancer.
Treatment: Increase Home Care/Personal Care HHC-Level II Personal Care Services Per 15 minutes To 24 Hour(s) Per Day (Live in).
The insurer denied the Increase Home Care/Personal Care HHC-Level II Personal Care Services Per 15 minutes To 24 Hour(s) Per Day (Live in).
The denial is overturned.

This female has conditions including chronic pain, post polio syndrome, cognitive decline, intracranial hemorrhage, and metastatic small cell lung cancer.  She is appealing denial of increase home care/personal care personal care services (PCA) 24 hours per day, live in.  The health plan approved 63 hours per week.  Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with housework and shopping; maximal assistance with meal preparation; extensive assistance with managing finances and medications, bathing, lower body dressing, and toilet transfer; limited assistance with phone, personal hygiene, upper body dressing, locomotion, toilet use, and bed mobility; and independent with eating. She is continent.  Uniform Assessment System (UAS) evaluation completed previously shows a decline in functioning with meal preparation, housework, managing finances and medications, stairs, shopping, bathing, personal hygiene, dressing, toileting, and eating.  She is frequently incontinent of bowel and bladder.   

An appeal statement from New York State indicated the patient has multiple chronic conditions and is wheelchair bound.  She has a new metastatic lesion to her brain and is status post craniotomy with parietal hematoma.  Note that logs show need for overnight assistance.

A letter from the provider notes the patient is wheelchair bound and requires assistance with ambulation and activities of daily living (ADLs).  She has cognitive decline.  She has nocturia and incontinence and needs assistance of an aide overnight.  Her son is no longer able to provide assistance.

Yes, the proposed increase in home care/personal care HHC-level II personal  care services per 15 minutes to 24 hour(s) per day (live in) is medically necessary.
Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  

This patient has multiple chronic conditions and is status post recent craniotomy for metastatic lesion to brain with residual parietal hematoma.  She is appealing denial of increase home care/personal care personal care services (PCA) 24 hours per day, live in.  The health plan approved 63 hours per week.  

Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLs).  She is incontinent of bowel and bladder.  Compared to Uniform Assessment Systems (UAS) evaluation completed previously, the patient's physical functioning has declined in all areas, and she has developed bowel and bladder incontinence.  The records and appeal statements support the patient's physical and cognitive status have declined and she is dependent with all activities of daily living (ADLs).  She is wheelchair bound.  She does not have informal support.  The information provide show that this patient has significant limitations in functioning.  The approved Personal Care Aide (PCA) services 63 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living (ADLs).  The proposed increase home care/personal care personal care services (PCA) to 24 hours per day, live in, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The increase in home care/personal care HHC-Level II personal  care services per 15 minutes to 24 hour(s) per day (live in) is medically necessary.