Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Arthritis, Dizziness

Treatment: Home Care/Personal Care HHC - Level 2 Personal Care Services, 35 hours per week of per 15 minutes

The insurer denied the home care/personal care HHC - Level 2 Personal Care Services, 35 hours per week of per 15 minutes. The denial was reversed. 

This is a female patient with history of hypertension, cerebral vascular disease, coronary artery disease, lumbar radiculopathy, dizziness, poor balance, h/o falls, depression, osteoarthritis of knee, difficulty walking. It was reported that the patient lives alone and requires assistance with her daily activities. She was getting person care services (PCA) for 25 hours a week five days a week and a request was made for an increase in hours to 35 hours a week 7 days a week. It was reported that the patient has difficulty with lifting due to her arthritis and lumbar radiculopathy.  She has lower back pain that radiates to lower extremities, which is consistent with neuropathic pain. She has neck spasms, and pain in her upper extremities that causes functional impairment; lifting. It was noted that she has dizziness that causes her gait to be unsteady. She requires assistance with various activities of daily living (ADLS); bathing, hygiene, dressing, toileting, and activities that include walking/transferring. 

The patient has several problems contributing to her functional impairment. She has arthritis with pain in her knees and lower back. Treatment for her arthritis pain includes voltaren gel and Tylenol. She also takes gabapentin which is often used for neuropathic pain. The physician's letter noted the patient has lumbar radiculopathy, and the UAS indicates patient has lower back pain radiating to lower extremities, which is consistent with neuropathic pain. The patient has neck spasms, and spasm type of pain of her upper extremities, with impairment of upper extremity function (decreased ROM, difficulty lifting). 

The patient has dizziness and poor balance. The cause is not specifically identified in the available records, but it was noted to be associated with change in position. The patient also takes several medications that can cause dizziness (antidepressants, gabapentin, antihypertensive drugs, lorazepam). Dizziness is a common symptom in older people, associated with decreased mobility, decline of functional ability for daily activities, and a significant risk factor for falls. 

Gait impairment was noted in the UAS and the physicians' letters. Pain and dizziness both contribute to gait instability. The patient did not have recent falls as per the UAS, but the diagnosis list includes history of falls. The patient is at high risk for falls due to symptoms (pain, weakness, dizziness) causing unsteady gait and poor balance. 

The patient's problems with upper extremity function can affect almost all daily activities, including household related tasks, and personal care activities (bathing, hygiene, dressing, toileting). Upper extremity pain or weakness also can adversely affect transfers and ambulation when use of an assistive device is necessary. 

Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. The patient needs assistance with IADLs and ADLs every day, i.e. 7 days per week. The question is who will provide the assistance. In the absence of informal caregivers who can provide satisfactory care to the patient on a consistent basis for 2 days per week, then personal care services are medically necessary to provide assistance 7days per week.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for 35 hours per week of Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes is substantiated.  The insurer's denial is reversed.