Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, encephalopathy, osteoarthritis, and spinal stenosis.

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.

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 modified.

This is an elderly male with chronic medical problems including coronary artery disease, encephalopathy, osteoarthritis, and spinal stenosis. He was hospitalized due to urinary retention and transferred to a skilled nursing facility. He otherwise lives in a 1-bedroom apartment. The insurer approved home care/personal care HHC - level 2 personal care services, per 15 minutes 49 hours per week. The request is for home care/personal care HHC - level 2 personal care services, per 15 minutes; 24 hours per day (live in).

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as "modified independent." He requires maximal assistance for bathing, lower body dressing and toilet transfer/use. The patient has a catheter for urinating and is infrequently incontinent of bowel. He requires extensive assistance for personal hygiene, upper body dressing and bed mobility. He requires supervision for eating. He is reportedly totally dependent for locomotion.  

During the time of the UAS assessment, the patient was a resident at a skilled nursing facility and receiving skilled physical and occupational therapy services. However, the associated physical and occupational therapy notes were not included for review. Based on the enclosed records made available for review, the patient's condition and functional needs are not at a level or unpredictable as to require the requested increased requested increase to 24 hours per day (live in). However, it is sufficient to support increasing services to 12 hours per day. This physician would also agree the patient may require additional monitoring. 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.

The healthcare plan acted reasonably, in part. 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, the requested home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in) is not medically necessary. However, increasing level 2 PCS, per 15 minutes to 12 hours per day is medically necessary. 

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 modified. Uphold denial for home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day live in. Approve home care/personal care HHC - level 2 personal care services, per 15 minutes 12 hours per day.