Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, hypertension and osteoarthritis. 
Treatment: home care / personal care HHC (home health care) - level 2 personal care services, per 15 minutes increase to 144 hours per week. 
The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 144 hours per week. 
The denial is modified. 
 
This is an elderly male diagnosed with Alzheimer's disease, hypertension and osteoarthritis. He lives alone in a 2-bedroom apartment. His daughter is described as a caregiver to her father by the patient's treating physician. She lives in the same apartment building. The insurer approved home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 72 hours per week. The insurer denied the request for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 144 hours per week leading to an external review. 

According to the Uniform Assessment System (UAS) report the patient's cognition is described as minimally impaired. He is reportedly total dependent for completing much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing. Extensive assistance is reportedly needed for lower body dressing and toilet use. Limited assistance is reportedly needed for upper body dressing and personal hygiene.  The patient is otherwise at the supervision level or independent for bed mobility, locomotion, ambulation and eating. The patient is reportedly frequently incontinent of bladder and continent of bowel. His ability to perform activities of daily living and his self-sufficiency has not changed over the prior 90 days. There also have been no reported falls over the prior 90 days. The patient's cognitive status is much the same when compared to the prior UAS report. His functional ability has only modestly decreased, particularly for bathing, lower body dressing and toilet use. 

Contrary to the assertions of his doctor, the patient is not totally incapacitated and does not  require assistance at all times. The patient's functional deficits are not at a level or unpredictable as to require the requested PCS (personal care services) 144 hours/week. This physician would agree, given the patient's reported progressive cognitive deficits, he may require additional monitoring for safety. However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the records reviewed and given his modest decline compared to the prior UAS report, the patient's health and safety can be appropriately provided and maintained by modestly increasing home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 86 hours per week.  

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 144 hours per week services is not substantiated. However, increasing home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 86 hours per week is medically necessary.