Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mobility issues, Confusion.
Treatment: Home care/personal care HHC level 2 personal care services per 15 minutes increase to 56 hours per week.
The insurer denied home care/personal care HHC level 2 personal care services per 15 minutes increase to 56 hours per week.
The determination is upheld.

This a male patient with a medical history notable for mobility issues and recent hospitalization for coronavirus (COVID) and pneumonia. The patient is currently receiving 28 hours per week of level 2 personal care services. The patient and his care team requested an increase to 56 hours per week, and this request was denied by the health plan.
A letter of medical necessity for this appeal was provided by the patient's physician. The physician states that the patient lives by himself and has "multiple mental and health problems," and that following the passing of his wife earlier this year his "memory deteriorated very fast, and he is depressed and confused all the time." He has home health from 8:00-12:00 every day and is alone until 6:00 PM. The physician states that during this time he is missing prescribed medications and meals and "forgets how to use the bathroom. He gets confused and depressed." The letter states that he requires medication four times daily, although the medication list that was provided lists only medications that are taken once daily. No medical records were provided for review.
A letter of support for this appeal was submitted by the patient's son. The letter states that the patient is "depressed and confused all the time." Much of the text in the appeal letter is substantially identical to the text from the physician letter of medical necessity.
A Uniform Assessment System (UAS) was completed and another assessment was completed 3 days prior. The assessment was repeated because the patient was recovering from an acute hospitalization and was showing improvements in function over a short period of time. The more recent assessment was completed in a nursing facility during this period of recovery from COVID and pneumonia. He was found to be self-directing in his care and not interested in consumer directed personal care services. He was alert and oriented times three, independent in decision making, and able to describe an emergency plan. He was directly observed doing transfers without an assistive device. From a functional standpoint, he requires maximal assistance for meal preparation, shopping, transportation, and housework. He requires extensive assistance for finances, medications, and stairs. He is independent with phone use. For his activities of daily living (ADLs), he requires limited assistance for bathing, dressing upper body, and dressing lower body. He is independent in all other ADLs. He is continent of stool and urine. A task tool associated with the more recent assessment recommended 21.33 hours per week to address his personal care needs. At issue is the medical necessity of home care/personal care HHC level 2 personal care services per 15 minutes increase to 56 hours per week.

The requested health service/treatment of home care/personal care HHC level 2 personal care services per 15 minutes increase to 56 hours per week has not been demonstrated to be medically necessary for this patient.
The patient's most recent Uniform Assessment System (UAS) recommended 21 hours per week to meet his functional needs, and he is currently approved for 30 percent (%) more than that at 28 hours per week. There is insufficient evidence that he has unmet personal care needs that would warrant additional hours. The letters make mention of four times daily medication, although this is not what is reflected in the medication list. Regardless, the regimen could be adjusted to accommodate the patient as needed. Personal care hours are not approved for safety monitoring and security alone in the absence of performing a personal care function. He does not have any unscheduled personal care needs that would warrant additional monitoring.