Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Home Care / Personal Care Level 2 Personal Care Services Increase to 72 Hour(s) per Week
The insurer denied: Home Care / Personal Care Level 2 Personal Care Services Increase to 72 Hour(s) per Week
The denial is overturned.

The member is an elderly male with a history of general debility due to osteoarthritis. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 25 hours per week based on Uniform Assessment System (UAS) of six months ago to 72 hours per week based on Uniform Assessment System of four months ago. The health plan denied the request because he has not shown that his activities of daily living have changed significantly, including physical functions like bed mobility, personal hygiene, upper/lower body dressing, walking, eating, meal preparation, housework, and medication management; and that the current needs are met by the previously adjusted Personal Care Assistance (PCA) hours; and that he had no memory issues. The additional hours requested are because of his chronic medical conditions with rapidly deteriorating mental and physical health leave him with poor functional status, cognitive impairment, reduced mobility, dependence on a walker and wheelchair. A review of the records showed that the member has multiple chronic medical conditions including hypertension, coronary artery disease (CAD), diabetes mellitus, diabetic neuropathy, benign prostatic hyperplasia (BPH), bladder/bowel incontinence, postural hypotension, ataxic gait, and decreased balance. Uniform Assessment System-New York (UAS-NY) evaluation of four months ago showed that he is minimally cognitively impaired with supervision required at certain times; independent with eating; requires limited assistance with walking, locomotion, toilet transfer, toilet use, bed mobility; requires extensive assistance with phone use, bathing, upper/lower body dressing; requires maximal assistance for managing finances, managing medications, transportation; and is totally dependent for meal preparation, housework, and shopping. He lives with his nephew and nephew's family in a 4-bedroom, 2-level private home.

The requested health service is medically necessary.

The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 25 hours per week based on Uniform Assessment System (UAS) of six months ago,
to 72 hours per week based on Uniform Assessment System of four months ago. The additional hours requested are because of his chronic medical conditions with rapidly deteriorating mental and physical health leave him with poor functional status, cognitive impairment, reduced mobility, dependence on a walker and wheelchair. A review of the records showed that the member has multiple chronic medical conditions including hypertension, coronary artery disease (CAD), diabetes mellitus, diabetic neuropathy, benign prostatic hyperplasia (BPH), bladder/bowel incontinence, postural hypotension, ataxic gait, and decreased balance. Uniform Assessment System-New York (UAS-NY) evaluation of four months ago showed that he is minimally cognitively impaired with supervision required at certain times; independent with eating; requires limited assistance with walking, locomotion, toilet transfer, toilet use, bed mobility; requires extensive assistance with phone use, bathing, upper/lower body dressing; requires maximal assistance for managing finances, managing medications, transportation; and is totally dependent for meal preparation, housework, and shopping. The reason for denial by the health plan as stated in the clinical information, does not align with the disability features as stated in the Uniform Assessment System of four months ago. Therefore, the 72 hours per week based on Uniform Assessment System of four months ago requested should be approved.