Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal
Home Health Care

Diagnosis: Osteoarthritis
Treatment: Home Care / Personal Care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 60 Hour(s) per Week

The insurer denied the request for Home Care / Personal Care (HHC) 

The health plan's determination is overturned in part. The patient should be approved for 50 hours per week as recommended by the task tool.

The patient is a female with medical history notable for osteoarthritis, type 2 diabetes mellitus, and urinary incontinence. The patient is approved for 26 hours per week of level 2 personal care services. The patient and her care team requested an increase to 60 hours per week.

The patient's daughter provided a letter of support for this appeal. The letter states that the patient's health and ability to care for herself has declined significantly over the past year after the passing of her husband. The patient is living alone and is having difficulties managing her daily tasks by herself. The patient's daughter disagrees with the health plan's assertion that there was no change on her assessment when compared to a prior assessment. She challenges the results of the most recent assessment which was conducted via video. She notes that the patient has had a fall while trying to get out of the car by herself. She has difficulty with walking straight due to dizziness and balance issues. This has led to several falls over the past year. The patient's daughter asserts that she needs to be assisted with all personal care tasks.

The patient's physician provided a brief note on a prescription pad for this appeal. The note states that the patient requires 6 hours per day, 7 days per week due to her medical conditions. Further detail was not provided.

A Uniform Assessment System (UAS) was completed and was available for review. The patient lives alone in a private home. She was alert and oriented but forgetful at times. She is able to make her needs known and direct her own care. For her Instrumental activities of daily living (IADL's), she requires maximal assistance for housework. She requires extensive assistance for meal preparation, stairs, and transportation. For her activities of daily living (ADL's) she requires limited assistance for bathing, hygiene, dressing, toilet transfers, and toilet use. She is independent for all other ADL's. She is occasionally incontinent of urine and infrequently incontinent of stool and uses Pull-Ups for incontinence care. When compared to the prior UAS, the patient showed decline in function in activities of daily living. A task tool associated with the most recent assessment recommended 50 hours per week to address her personal care needs.

The requested health service of Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 60 Hours per Week has not been demonstrated to be medically necessary for this patient.

The patient has shown a decline in functional status as documented by the UAS and by the letter from the patient's daughter. She requires assistance for numerous IADL's and some ADL's. A task tool recommends 50 hours per week to address her needs. This is also roughly in line with what the patient's physician is recommending. The patient's recent falls are evidence of unmet personal care needs. Therefore, increasing the patient's personal Care hours to 50 per week is medically necessary and appropriate for the patient.

There was no documentation provided or justification for why the requested 60 hours per week would be medically necessary, and why the task tool's recommendation of 50 hours per week would not be sufficient for the patient. Therefore, the health plan's decision is overturned in part.

The health plan's determination of medical necessity is overturned in part, the patient should be approved for 50 hours per week as recommended by the task tool.