Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Schizophrenia. 
Treatment: Home care / personal care HHC (home health care) - level 2 personal care services, per 15 minutes increase to 24 hours per day live in services. 
The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day live in services. 
The denial is modified. 

This is a patient with chronic medical problems including diabetes, heart disease and schizophrenia. The patient lives with their sister in a 2-bedroom apartment. The patient is currently receiving home care / personal care Home Health Care (HHC) level 2 personal care services, per 15 minutes, 56 hours per week. The request is for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day live in; which was denied by the insurer and currently under review. 

The Uniform Assessment System (UAS) finalized report was reviewed. The patient's cognitive skills are described as minimally impaired. The patient reportedly is total dependent for much of their Instrument Activities of Daily Living (IADLs) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, personal hygiene, dressing and toilet transfer/use.  Extensive assistance is reportedly needed for eating, locomotion and ambulation.  The patient reportedly requires supervision for bed mobility. The patient is reportedly frequently incontinent of urine and occasionally incontinent of bowel. The patient's activities of daily living (ADLs) status and self-sufficiency have reportedly not changed and there have been no reported falls over the prior 90 days. 

A letter from the patient's treating psychiatrist was reviewed. The patient's psychiatrist indicates the patient is "fully dependent on caregiver to assist with ADLs and IADLs."  The patient's psychiatrist recommends additional home care hours for the patient.  However, The patient's psychiatrist does not provide associated office visits describing any specific functional assessment or particular impairment consistent with the assertion of the patient's reported functional incapacity. 

Also submitted for review are treatment notes from primary care physician. According to the latter note, the patient lives with their sister who is their guardian. The patient's primary care physician indicates the patient's "medical conditions require more home health aide (HHA) services in order to complete their ADL as listed above." 

The patient's medical condition, physical limitations and functional ability are not at the level or unpredictable as to require the requested live-in personal care services (PCS). However, the clinical records reviewed are consistent with the patient having cognitive and physical impairments that warrant increasing PCS. It is agreed that the patient may benefit from additional monitoring; particularly due to their reported weakness, cognitive/vision impairments and falls risk. However, safety monitoring under PCS does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the records reviewed as discussed above, attention to the patient's health and safety can be appropriately provided and maintained by increasing PCS to 12 hours/day (perhaps 2 separate shifts), 7 days/week, totaling 84 hours/week. 

Based on the above, the insurer's denial must be modified. 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 live in services is not substantiated.  However, increasing PCS to 12 hours/day (perhaps 2 separate shifts), 7 days/week, totaling 84 hours/week is approved.