Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis

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

According to the documentation submitted, this is an adult with a history of coronary heart disease, hyperlipidemia, osteoarthritis, non-Hodgkin lymphoma, and a pressure ulcer on the buttock. Per the Uniform Assessment for New York (UAS-NY), the patient lives with their son. The patient needs assistance with many activities of daily living (ADL's). 

The insurer has 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), as not medically necessary. In a Final Adverse Determination letter, they stated that the plan initially approved home care / personal care HHC - level 2 personal care services, per 15 minutes 84 hours per week. The plan approval increased to and stays at home care / personal care HHC - level 2 personal care services, per 15 minutes increase to live in services. The UAS-NY was reviewed. The member was reassessed, and the hours were adjusted accordingly. 

The patient's daughter is appealing. In an appeal letter the patient's Cardiologist, stated that the patient has physical impairments limiting the patient's ability to care for themselves and perform ADL's. The patient needs split shift services to meet their needs. 

According to the medical records, the patient has knee and shoulder arthritis and uses a wheelchair for ambulation. The patient transfers with a sliding board and has a Hoyer lift. The patient has some neuropathic pain in their legs and has a pacemaker. The patient's medications are Tramadol for pain, testosterone gel, and one statin. The patient's daughter states the patient has some confusion, though no abnormalities were noted on computerized tomography (CT) scan exam. The patient has an adult daughter who gives informal support. The patient has been noted to be difficult and walked out of a physician's office. The patient's son lives in another apartment and receives 24-hour services for multiple sclerosis. The request is for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift), which is under review.

There is a letter from the physician which notes the patient's inability to reposition themselves or get up from bed to use the bathroom. "The patient soils themselves and then sits in their soiled diaper until an aide comes."  The provider also noted skin breakdown and intermittent sacral ulcers. 

The patient is not mobile, cannot reposition themselves and as noted by their physician has had issues with skin breakdown.  

Based on the above, the insurer's denial must be reversed. 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 HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift) is substantiated.