Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, hypertension, gastroesophageal reflux disease (GERD), transient ischemic attack (TIA), osteoarthritis (OA), glaucoma, and hearing loss

Treatment: Home care/ personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in)

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).  The denial is overturned.

This elderly female has experienced functional decline associated with several medical conditions. She was living with her husband, but he was admitted to a skilled nursing facility. She has been staying with her son and his family temporarily. The patient needs assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs), so the family has been providing care until the patient can receive personal care services. At that time, she will return to her apartment (living alone). The insurer approved personal care services 50 hours per week. The patient requested increase of services to 24 hours per day live-in, which was denied. 

The most recent Uniform Assessment System (UAS) report provided was reviewed. The functional status for IADLs indicates patient was totally dependent for ordinary housework, meal preparation, managing finances, shopping; she needed maximal assistance for managing medications, phone use, transportation; extensive assistance for stairs. For ADLs, she needed extensive assistance for bathing, dressing lower body; limited assistance for dressing upper body, walking, locomotion; setup help for personal hygiene, toilet use, eating, bed mobility; supervision for toilet transfer.

The patient is experiencing health challenges related to pain, hearing and vision loss, cognitive decline which have caused significant limitations of routine daily function. Several months ago, her husband had to leave their home because of his health problems. When the patient returns to her home, she will probably experience an adjustment period, as she may be living in her home alone for the first time. She has been accustomed to having her family assist her since she moved to her son's house temporarily. 

Considering the information provided, it is medically necessary, and in the patient's best interest to have a caregiver assist with all daily activities. The patient needs assistance with all housekeeping tasks; food preparation/service with cues and reminders when eating; assist/supervise with medications; assist with routine ADLs (dressing, bathing, personal hygiene) and ADLs that occur at various unscheduled times throughout the day and night (e.g., walking, transfers, toileting). 

Managed Long Term Care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. These care needs must be considered in the determination of the patient's personal care service hours. Additional personal care services would not be for stand-alone safety supervision. Assistance is necessary to help ensure safe, effective performance of ADLs and IADLs and help prevent adverse health and safety events, e.g., falls/injuries, skin injury (related to incontinence), malnutrition, dehydration, incorrect use of medications.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Home care/ personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in) is overturned. Medical Necessity is substantiated.