Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer, chronic obstructive pulmonary disease (COPD), hypertension. 
Treatment: Home Care/Personal Care HHC - Level 2, Personal Care services, per 15 minutes, increase to 84 hours per week. 

The insurer denied coverage for Home Care/Personal Care HHC - Level 2, Personal Care services, per 15 minutes, increase to 84 hours per week. 

The denial is overturned. 

This case involves an adult patient who was requesting an increase to 84 hours/week of personal assistant services. Records stated the patient lives in a 2 bedroom, first-floor apartment with her daughter-in-law and son. According to the recent assessment the patient denied hospitalizations, falls, or emergency room visits for the last 90 days. She was last hospitalized some time ago and then transferred to rehabilitation. She suffered a fall causing a hip fracture and subsequent hospitalization for 1 week. She then transferred to rehabilitation facility and subsequently discharged. She was receiving 35 hours/week of personal care assistance at the time of the assessment. The report noted the patient was minimally impaired cognitively with no significant memory problems.  The patient had some difficulties with communication but had adequate hearing and minimal difficulty with vision. There were no motor behavioral issues documented. The patient was totally dependent for meal preparation and required extensive assistance with managing finances and medications as well as phone use. She was totally dependent for navigating stairs, shopping, and transportation as well as with bathing.  She needed maximal assistance with personal hygiene measures and dressing the upper body. She was totally dependent for dressing the lower body and was locomotion, transferring off on the toilet, and with toilet use. She needed extensive assistance with bed mobility and with eating and typically uses wheelchair or scooter for locomotion indoors.  

Personal assistant services allow patients to remain in the comfort of their own home to receive treatment rather than living in a skilled nursing facility or an assisted living. The documentation provided for the review stated that the patient was denied coverage for 84 hours/week of personal care services with claims that there was no report of bladder or bowel incontinence. However, the recent assessment notes the patient has an indwelling catheter and wears diapers at night and requires an ostomy bag for bowel control. She is considered wheelchair/bedbound and requires maximum, extensive, and total dependence on others for most activities of daily living and instrumental activities of daily living. Given her extensive physical deficits, it was determined that the request for 84 hours of personal care services is reasonable. As such, the increase to 84 hours/week 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 HHC - Level 2, Personal Care Services, per 15 minutes, increase to 84 hours per week is substantiated.