Diagnosis: Osteoporosis/frequent falls.
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services: 70 Hours per Week.

The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services: 70 Hours per Week.
The health plan's determination is overturned.

The patient is a female with past medical history of diabetes mellitus type 2, hypertension, hyperlipidemia, congestive heart failure (CHF), chronic kidney disease, severe arthritis with chronic pain, osteoporosis, neuralgia, urinary retention and recurrent falls who had been assigned personal care services.

The patient underwent another assessment tool via telephone assessing patient at total assistance with tasks of meal preparation and ordinary housework while maximum assistance with tasks of shopping, bathing, and toilet use. With tasks of managing finances, managing medication, stairs, transportation, dressing lower body, transfer toilet, and bed mobility the patient was assessed at extensive assistance while limited assistance with tasks of phone use, personal hygiene and dressing upper body. The patient was assessed at supervision with tasks of walking, locomotion, and eating. Notes from this assessment stated patient had a Foley catheter in place and was using pull-ups to manage leaks. In addition, the report stated the patient had unsteady gait and ambulated using a cane supported by daughter when transferring and changing positions.

Home Care / Personal Care HHC - Level 2 Personal Care Services: 70 Hours per Week are medically necessary for this patient.
There is documentation of worsening physical functioning following hospitalization. There is documentation of recurrent falls. The patient's medical provider requested an increase in Home Care / Personal Care services. The assessment tools show an increased need for assistance with tasks of meal preparation, phone use, bathing, dressing upper body, toilet use, bed mobility and eating. The patient did have improvement with walking and locomotion as well as personal hygiene but patient was still noted to require at least some assistance for these tasks.
As the patient requires at least some assistance with all activities of daily living (ADL)/ Instrumental activities of daily living (IADL) and the requested increase in Home Care / Personal Care Services is not solely for safety and supervision but to assist the patient with safe completion of ADLs. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet the patient's care needs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care / Personal Care HHC - Level 2 Personal Care Services: 70 Hours per Week are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.