Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke with left hemiparesis, hypertension and depression
Treatment: Home Care/Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per Day (Split Shift)
The insurer denied coverage for Home Care/Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per Day (Split Shift)
The denial is overturned

This is a geriatric patient with medical problems that include stroke with left hemiparesis, hypertension and depression. The patient lives with the spouse in a private residence. The insurer approved Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per Day (Live In) and the request is for Home Care/Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per Day (Split Shift).

According to the Uniform Assessment System (UAS) report, the patient's cognition is described "minimally impaired." However, the clinical records are consistent with an individual who is more severely (cognitive) impaired. The patient exhibits total dependence for much of the Instrumental Activities of Daily Living (IADL) (tasks including meal preparation, ordinary housework and shopping). The patient also exhibits total dependence for lower body dressing and toilet use; has a Foley catheter and is infrequently incontinent of bowel. The patient requires maximal assistance for personal hygiene and toilet transfer. Extensive assistance is needed for upper body dressing and eating. The patient is bed bound with essentially no ability to perform transfer tasks or ambulate.

The patient's clinical condition, cognitive ability and severe functional deficits continue to decline and are at a level of need and unpredictable as to require the requested Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per Day (Split Shift). Of particular concern is the bedbound status, risk of pressure ulcers and progression of the joint contractures with underlying hemiparesis. This is in addition to the Foley catheter management and bowel incontinence. The patient requires routine repositioning in bed at least every 2-3 hours. Based on the clinical records, a live-in home care/personal care aid is unlikely or capable of obtaining approximately 5 hours of uninterrupted sleep over the course of a 24-hour shift. This physician would agree that attention to the patient's functional needs are more appropriately provided and maintained by the requested Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per Day (Split Shift).

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.

From a physical medicine and rehabilitation perspective, the requested Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per Day (Split Shift) is medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for Home Care/Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per Day (Split Shift) is substantiated.