Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, Lupus, Coronary Artery Disease 

Treatment: home care / personal care home health 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 home health care (HHC) - level 2 personal care services, per 15 minutes increase to 84 hours per week

The denial is modified

This is a patient with chronic medical problems including hypertension, lupus and coronary artery disease. The patient lives alone in a private residence. The patient is approved by the insurer for personal care assistance (PCA) services 42 hours/week. A denial of coverage for Home Care/Personal Care Home Health Care (HHC) - Level 2, Personal Care Services, per 15 minutes, increase to 84 hours per day has resulted in an external review.

According to the Uniform Assessment System (UAS) report. The patient's cognition is described as minimally impaired. The patient is reportedly total dependent to maximal assistance for performing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, lower body dressing, and toilet use. Extensive assistance is reportedly needed for personal hygiene, upper body dressing, locomotion, toilet transfer and ambulation. Limited assistance is reportedly needed for bed mobility and supervision for eating. The patient is reportedly frequently incontinent of bladder and infrequently incontinent of bowel. 

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require Home Care/Personal Care HHC - Level 2, Personal Care Services, per 15 minutes, increase to 84 hours per week. This physician would agree that the patient may benefit from additional monitoring; particularly due to her reported cognitive decline and falls risk. However, safety monitoring under personal care services (PCS) does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided. Based on the documents reviewed, the UAS reports document modest cognitive and functional declines. The patient's functional needs can be appropriately provided and maintained via increasing PCA services 8 hours/day, 7 days/week, total 56 hours/week. The patient also has the option of restructuring and flexibly using the 56 PCA hours weekly to better maintain and meet her functional needs. 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, Home Care/Personal Care HHC - Level 2, Personal Care Services, per 15 minutes, increase to 84 hours week is not medically necessary. However, increasing Home Care/Personal Care HHC - Level 2, Personal Care Services, per 15 minutes, increase to 56 hours week is medically necessary. 

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 84 hours per week is not substantiated. However, increasing Home Care/Personal Care HHC - Level 2, Personal Care Services, per 15 minutes, increase to 56 hours week is medically necessary.