Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, coronary artery disease, morbid obesity, anemia, osteoarthritis, spinal stenosis, memory loss, sleep apnea, and Alzheimer's dementia
Treatment: Increase in Home Health Care (HHC) level 2 per 15 minutes to 84 hours/week
The insurer denied: Increase in HHC level 2 per 15 minutes to 84 hours/week.
The denial is overturned.

The patient is an elderly female. Her medical conditions include hypertension, coronary artery disease, morbid obesity, anemia, osteoarthritis, spinal stenosis, memory loss, sleep apnea, and Alzheimer's dementia. Denial of increase home health care (HHC) to 84 hours/week is being appealed. The health plan approved 48 hours/week.

Uniform Assessment System (UAS) evaluation completed 5 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, phone use, bathing, dressing, and toilet use; extensive assistance with personal hygiene, walking, locomotion, toilet transfer, and bed mobility; and supervision with eating. The patient has bowel and bladder incontinence. Compared to UAS evaluation completed last year, there has been a decline in functioning with bed mobility.

An appeal statement notes the patient has multiple conditions and needs assistance with all ADLs (activities of daily living). Her mobility has declined over the past few months, and she requires significant assistance with weight bearing. She now predominantly sits in a rollator and is pushed by aide. She has frequent episodes of urinary incontinence. She lives with her daughter who had to return to work full-time outside of the home. Her daughter provides 5 hours of informal support per day. The patient is unable to use the bedside commode without assistance. She requires assistance with sitting up and transferring.

A letter from the patient's provider notes the patient has multiple chronic conditions and requires assistance with ADLs. She falls when she attempts to ambulate without assistance.

A letter from the patient's daughter notes the patient needs constant assistance. The patient has progressive dementia and is unable to walk on her own. She is unable to live on her own.

The increase in HHC level 2 per 15 minutes to 84 hours/week is medically necessary.

Personal assistance services provide hands-on assistance to individuals to include assistance with ADLs, health maintenance activities, and routine support services. Denial of increased HHC to 84 hours/week is being appealed. The health plan approved 48 hours/week.

This patient has multiple chronic conditions. UAS evaluation completed 5 months ago shows moderately impaired cognition and the patient requires extensive assistance to total dependence with all ADLs, except with eating. Compared to UAS evaluation completed last year, there has been a decline with bed mobility. Appeal statements note there has been a progressive decline in the patient's cognitive and physical functioning. She now predominantly sits in a rollator and is pushed by aide. She requires assistance with all ADLs, including weight bearing, sitting up, and transferring. She also requires reminders and prompting. Her daughter is no longer able to provide extensive informal assistance as she has returned to full-time work. The information provided shows that this patient has significant limitations in functioning. She has limited informal support. The approved HHC of 48 hours/week is insufficient to meet this patient's needs for assistance with ADLs. The requested increase to 84 hours/week is medically necessary.