Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End stage renal disease. 
Treatment: Home Care / Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 minutes Increase to 56 Hour(s) per Week. 
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 56 Hour(s) per Week. 
The determination is partially overturned. 

This is a male patient with a medical history notable for end stage renal disease. The patient is approved for 24 hours per week of personal care services. The patient and his care team requested an increase to 56 hours per week, and this request was denied by the health plan. 
The patient's physician provided a letter of support for this appeal. The letter states that the patient has a medical history notable for recurrent Clostridium difficile (C diff) colitis, human immunodeficiency virus (HIV), coronary artery disease, peripheral artery disease, chronic kidney disease, and obstructive sleep apnea. They state that the current amount of hours is "not sufficient to handle a case with his medical complexities." They state that his medical problems make it difficult for him to complete activities of daily living such as ambulating, eating, and dressing. They state that additional hours would greatly benefit the patient's quality of life. 
The patient provided a letter of support on his own behalf. He states that he needs the additional hours to help escort him to his medical appointments. He is also not able to ambulate independently at home. 
A Uniform Assessment System (UAS) was completed. The patient lives alone in an apartment and currently receives dialysis three times per week. His cognition was intact with independent decision making. For his instrumental activities of daily living, the patient requires maximal assistance for meal preparation, housework, and shopping. He requires extensive assistance for transportation. For his activities of daily living, the patient requires extensive assistance with bathing and dressing lower body. He requires limited assistance with hygiene, dressing upper body, toilet transfer, toilet use. He is independent for bed mobility and eating. The patient was observed walking with a rollator walker with an unsteady gait. He is continent of urine and stool. There was no fall within the previous 90 days. A task tool associated with the assessment recommended 27.25 hours per week to address his personal care needs. Compared to a prior assessment, the patient did not show a significant decline in functional status. At issue is the medical necessity of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 56 Hour(s) per Week. 

The requested health service of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 56 Hour(s) per Week has not been demonstrated to be medically necessary for this patient. However, at a minimum, 28 hours per week as recommended by the task tool is medically necessary. 
The patient requires assistance with multiple home care tasks, especially for instrumental activities of daily living. He does require some assistance with bathing and dressing. The documentation provided does not demonstrate that any personal care needs are not currently being met for the patient. Therefore, there is insufficient evidence that the requested increase to 56 hours per week is medically necessary for the patient. However, the task tool does recommend 27.25 hours per week to address the patient's personal care needs.