Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Legally blind, hypertension, anemia, chronic obstructive pulmonary disease (COPD), arthritis, depression, hypothyroidism, glaucoma, gastroesophageal reflux disease (GERD).
Treatment:  Home Care / Personal Care Level 2 Personal Care Services Increase to 50 Hour(s) per Week.

The insurer denied Home Care / Personal Care Level 2 Personal Care Services Increase to 50 Hour(s) per Week.  
The denial is overturned.

The patient is an elderly female with a history of general debility, who is also legally blind. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 42 hours per week based on Uniform Assessment System (UAS) of 8 months ago to 50 hours per week based on Uniform Assessment System of 4 months ago. The health plan denied the request because the patient has not shown that her activities of daily living have changed significantly, including physical functions like bed mobility, bathing, personal hygiene, upper/lower body dressing, walking, eating, meal preparation, housework, and medication management. In addition, the current needs are met by the previously adjusted Personal Care Assistance (PCA) hours. The additional hours requested are because of the patient's chronic medical conditions and also 
because she is legally blind, has hypertension, and is hindered from performing her activities of daily living because of her blindness. She needs help with her activities of daily living. A review of the records showed that the patient has multiple chronic medical conditions including being legally blind, hypertension, anemia, chronic obstructive pulmonary disease (COPD), arthritis, depression, hypothyroidism, glaucoma, and gastroesophageal reflux disease (GERD). Uniform Assessment System-New York (UAS-NY) evaluation of 4 months ago showed that the patient required extensive assistance with mobility, walking, locomotion, transfer toilet, toilet use, and eating; required maximum assistance with upper/lower body dressing, and bathing; and was totally dependent for meal preparation, medication management, and housework. Her family support is very limited as she lives alone in an apartment on the first floor.

The requested health service is medically necessary.

The requested increase for Personal Care Assistance through Home Health Care (Level 2) from 42 hours per week based on Uniform Assessment System (UAS) of 8 months ago to 50 hours per week based on Uniform Assessment System of 4 months ago is medically necessary. The additional hours requested are because of the patient's chronic medical conditions and also because she is legally blind, has hypertension, and is hindered from performing her activities of daily living because of her blindness. She needs help with her activities of daily living. A review of the records showed that the patient has multiple chronic medical conditions including being legally blind, hypertension, anemia, chronic obstructive pulmonary disease (COPD), arthritis, depression, hypothyroidism, glaucoma, and gastroesophageal reflux disease (GERD). Based on the most recent Uniform Assessment System of 4 months ago, the patient was legally blind, minimally cognitively impaired with supervision required at all times; she required limited assistance with managing medications, bed mobility, eating; required extensive assistance with phone use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, required maximal assistance for meal preparation, managing finances, shopping, transportation, bathing, lower body dressing, toilet use, and was totally dependent for housework. The reason for denial by the health plan as stated in the clinical information above does not align with the patient's disability features as stated in the Uniform Assessment System of 4 months ago as stated above. Therefore, the 50 hours per week as requested based on Uniform Assessment System of 4 months ago should be approved.