Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis, anemia, hyperlipemia, dementia, chronic pain, asthma, hypertension, low back pain, dizziness and giddiness, difficulty walking, and diabetes. 
Treatment: Increase Home Care/Personal Care HHC Level 2 Per 15 Minutes To 84 Hours Per Week. 

The insurer denied: Increase Home Care/Personal Care HHC Level 2 Per 15 Minutes To 84 Hours Per Week. 

The denial is overturned. 

The patient is an elderly female. Her conditions include arthritis, anemia, hyperlipemia, dementia, chronic pain, asthma, hypertension, low back pain, dizziness and giddiness, difficulty walking, and diabetes. The denial of increase home care/personal care to 84 hours per week is being appealed. The health plan approved 49 hour per week. Uniform Assessment System (UAS) evaluation completed 3 months ago shows modified independent cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; extensive assistance with managing medications, phone use, stairs, transportation, bathing, lower body dressing, walking, locomotion, and toileting; limited assistance with personal hygiene, upper body dressing; and independent with bed mobility and eating. The patient has frequent bladder incontinence. Compared to UAS (uniform assessment system) evaluation completed last year, there has been a functional decline with managing finances, phone use, and toileting. A letter from a provider notes the patient has rapidly deteriorating mental and physical health. She is unable to walk independently and is mostly wheelchair dependent. She has multiple chronic conditions. She requires continuous supervision and assistance. She cannot perform ADLs (activities of daily living) independently. An appeal letter notes the patient lives alone. She cannot call for help due to dementia. She is unable to transfer from bed and is mostly wheelchair dependent. She is in bed for 17 hours a day and is found covered in urine and feces. 

The requested Increase Home Care/Personal Care HHC Level 2 Per 15 Minutes To 84 Hours Per Week is medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. The denial of increase home care/personal care to 84 hours per week is being appealed. The health plan approved 49 hour per week. This patient has multiple chronic conditions. She lives alone and is wheelchair dependent. Uniform Assessment System (UAS) evaluation completed 3 months ago shows she requires assistance with all ADLs (activities of daily living), except bed mobility and eating. She has frequent bladder incontinence. Compared to UAS (uniform assessment system) evaluate completed last year, there has been a functional decline with managing finances, phone use, and toileting. Appeal statements support her being wheelchair dependent and requiring assistance with ADLs (activities of daily living). There has been a decline in the patient's functioning between UAS (uniform assessment system) evaluations. This patient has functional impairments that require significant assistance with ADLs (activities of daily living). The approved personal care at 49 hours per week is insufficient to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The requested increase to 84 hours per week is medically necessary.