Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Incontinence/Urinary/Bladder Control
Treatment: Home Health Care: 168 Hours/Week, Consumer Direct, 1 client
The insurer denied Home Health Care: 168 Hours/Week, Consumer Direct, 1 client.
The determination is upheld.

This patient has a medical history notable for vascular dementia, prior cerebrovascular accident, gait difficulty, and urinary incontinence. The patient is currently approved for 56 hours per week of consumer directed personal care services. The patient and their care team requested an increase to 168 hours per week, and the insurance company partially denied this request; they did approve an increase to 70 hours per week. At issue is the medical necessity of the requested health service/treatment of 168 hours per week, consumer direct, 1. 

A letter of support for this appeal was provided by the patient's nurse practitioner who has been treating the patient since April 2022. The letter states that the patient is not capable of toileting and changing by themselves and must be checked and changed throughout the day and night to ensure proper toileting hygiene. If the patient does not receive this care, they are at high risk for urinary tract infections. The letter specifically requests 10 hours per day for 7 days to address personal care needs. A letter of support for this appeal was also provided by the patient's physician. The letter states that the patient has difficulty with completing activities of daily living (ADL) and requires assistance with changing soiled pull-ups and toileting. The patient requires support during the day and night for incontinence episodes. The letter specifically requests 10 hours per day to address their personal care needs.

Office visit notes were provided for review. Notes from 10/11/22 state that the patient has been falling frequently when they are alone in the evening after their aide leaves for the day; the patient's daughter has found them on the ground several times. The patient's daughter began taking the patient to her home due to their risk of falls. They have a fall alert bracelet but had not yet started using it. The note states that the patient "currently [receives] 8 hours per day for 7 days. Needs 24 hours care." The patient was also having polyuria due to suboptimal diabetes control. The patient's hemoglobin A1c was 7.0 but random glucose on a metabolic panel was 295.

A Uniform Assessment System (UAS) was completed on 5/20/22 and was available for review. The patient was alert and oriented times three and able to make their needs known, but does have episodes of forgetfulness. The Mini-mental state examination score was 25 out of 30 which is classified as normal. For the patient's Instrumental activities of daily living (IADL), they require maximal assistance for meal preparation, housework, and shopping. The patient requires extensive assistance for managing medications and transportation. For the patient's activities of daily living (ADL), they require extensive assistance for bathing, dressing upper/lower body, walking, locomotion, and toilet transfer. They require limited assistance for hygiene, eating, and toilet use. They require supervision only for bed mobility. The patient is occasionally incontinent of urine and continent of stool. The patient uses pull-ups for incontinence care. A task tool associated with the assessment recommended 31 hours per week for the patient's personal care needs. Compared with a prior assessment from 10/8/21, there was no significant change in the patient's cognitive or functional status.