Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertension, diabetes mellitus, Alzheimer's disease, insomnia, diabetic neuropathy, low back pain, urinary incontinence, coronary artery disease, anxiety, depression, gout, and falls.

Treatment: Home Care/Personal 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 HHC - Level 2, Personal Care Services, per 15 minutes, increase to 84 hours per week.

The denial is modified.

This is a geriatric patient with hypertension, diabetes mellitus, Alzheimer's disease, insomnia, diabetic neuropathy, low back pain, urinary incontinence, coronary artery disease, hyperlipidemia, anxiety, depression, gout, and falls.

Per the cited references, personal care services are the provision of some or total assistance with personal hygiene, dressing, and feeding and nutritional and environmental support. The services must be essential to the maintenance of the patient's health and safety in their home, be ordered by a physician or nurse practitioner, and be based on an assessment of the patient's needs for the service in accordance with guidelines. The patient must have a stable medical condition that does not require frequent medical or nursing judgment to determine changes in the patient's plan of care. Allotment of time separate and apart from personal care tasks authorized is not required for safety monitoring. However, there is a clear and legitimate distinction between safety monitoring as a nonrequired stand-alone function while no personal care services are being provided and the appropriate level of safety monitoring while the patient is receiving assistance with personal care services such as transferring, toileting, or walking.

In this case, the patient has a significant change in status. The patient required additional assistance during the daytime. There was noted cognitive impairment. The patient reported forgetfulness and problems with short-term memory. The patient's medical conditions had become progressively worse. The patient had experienced insomnia, headaches, unstable gait, and severe dizziness. The patient complained of frequent urination, forgetfulness, depression, and frequently cries for no reason. The patient was unable to prepare a meal or self-administer medications. The patient required assistance in daily activities and would benefit from an increase in home care aide hours. Based on the documentation, an increase in personal assistance hours is medically necessary for the patient. The patient has had significant decline in functional status. The patient required supervision for multiple tasks in which they were previously independent. Given the patient's dizziness, recent fall, and decline in functional capabilities, the patient would require supervision and assistance with all daily ambulation and transfers. The 30 hours a week would be insufficient to address all the patient's functional deficits and new needs. The patient is at risk of continued loss of function and injury without increased hours. However, the patient's treating provider indicated that the patient would be appropriate for 8 to 10 hours daily. The requested 84 hours (12 hours per day) appears excessive given the patient's treating provider recommendation for 8 to 10 hours. Thus, the denial is partially overturned for authorization of home care/personal care HHC-level 2, personal care services, per 15 minutes, increase to 70 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 84 hours per week is not substantiated. However, the denial is partially overturned for authorization of home care/personal care HHC-level 2, personal care services, per 15 minutes, increase to 70 hours per week.