Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis. 
Treatment: Home Care / Personal Care Level 2 Personal Care Services Increase to 84 Hours per Week. 
The insurer denied Home Care / Personal Care Level 2 Personal Care Services Increase to 84 Hours per Week. 
The determination is overturned. 

This is a male patient with a medical history notable for multiple sclerosis, incontinence, and bed confinement status. The patient is approved for 63 hours per week of personal care services. The patient and his care team requested an increase to 84 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 has multiple sclerosis with weakness of the upper and lower extremities, severe deconditioning, bowel and bladder incontinence, and bedridden status. The patient was diagnosed with multiple sclerosis and has had rapid progression of his disease with neurological decline and loss of functional independence. The additional hours of home health are needed to help with completion of activities of daily living and repositioning in bed to avoid pressure ulcers. The patient requires total care with all aspects of his activities of daily living due to weakness and inability to move independently. He requires additional hours as his elderly parents are unable to assist him anymore due to their own health decline and physical needs. 
A Uniform Assessment System was completed. The patient lives alone in an apartment building. He was alert and oriented and able to direct his own care. His 5-minute recall was one out of three. For instrumental activities of daily living, the patient requires total dependence for meal preparation, housework, stairs, shopping, and transportation. He requires extensive assistance for finances, medications, and phone use. For his activities of daily living, he requires total dependence for bathing, dressing upper body, dressing lower body, and toilet use. He requires maximal assistance for personal hygiene and bed mobility. He requires extensive assistance for eating. He is frequently incontinent of both urine and stool and uses Pull-Ups for incontinence care. There was no fall in the previous 90 days. There was no pressure ulcer present. At issue is the medical necessity of Home Care / Personal Care Level 2 Personal Care Services Increase to 84 Hours per Week.

The requested health service of Home Care / Personal Care Level 2 Personal Care Services Increase to 84 Hours per Week is medically necessary for this patient. 
The patient requires extensive help with activities of daily living including bed mobility, toileting, transfers, locomotion, and incontinence care. He is not able to complete any of these tasks on his own. These tasks are expected to be continuous and unscheduled throughout the day and occasionally at night as well. He is no longer able to receive informal support from his parents. Therefore, it is medically necessary for the patient to receive the requested increase to 84 hours per week of personal care assistance. Failure to address the patient's personal care needs could result in skin breakdown and/or infection.