Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease. 
Treatment: Home Care/Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 minutes increase to 70 hours per week. 
The insurer denied coverage for Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 70 hours per week. 
The denial is modified. 

This is patient with multiple medical problems including Parkinson's disease, diabetes and history of hydrocephalus. The patient lives with their spouse and son in a private residence. The patient requested an increase in Home Care/Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes from 38 to 70 hours per week. The insurer increased Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes to 42 hours per week, leading to an external review. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as moderately impaired. The patient's son directs the patient's care. The patient is reportedly total dependent for completing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, lower body dressing, locomotion, toilet transfer/use and ambulation. Extensive assistance is reportedly needed for personal hygiene, upper body dressing, bed mobility and eating.  The patient is reportedly frequently incontinent of bladder and bowel. The patient's activities of daily living (ADL) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days.  There have been no reported falls over the prior 90 days. The patient's cognitive and functional ability have declined when compared to the UAS report. 

The letter from the patient's treating physician describing the patient's clinical condition and need for additional home care services was reviewed. The provider does not include the associated treatment notes to support the claim of the patient's reported functional incapacity.  The patient's medical condition and physical limitations are not at the level or unpredictable as to require the requested Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes 70 hours/week.  The patient's cognitive and functional ability have declined and supports increasing the patient's currently approved Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes from 42 to 56 hours per week.  Based on the records reviewed, the patient's health and safety are more appropriately provided and maintained by continuing shared household responsibilities of the other adults living in the home, informal care from family and increasing Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes to 56 hours per week.  

The healthcare plan did not act with sound medical judgment or in the best interest of the patient. (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). 

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 70 hours per week is not substantiated. However, Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 56 hours per week is medically necessary.