Diagnosis: Hypertension, hyperlipidemia, neuropathy, metastatic uterine cancer and depressive disorder.
Treatment: Home Health Care (HHC)/Personal Care - Level 2 Personal Care Services (PCS), per 15 minutes Increase to 42 Hour(s) per Week.

The insurer denied coverage for Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 42 Hour(s) per Week.

The denial is overturned.

This is an elderly patient with chronic medical problems including hypertension, neuropathy and more recent metastatic uterine cancer. She was hospitalized and underwent a hysterectomy. The patient lives with her spouse in a 1-bedroom apartment. She is currently approved for PCS 32 hours/week and requesting an increase to 42 hours/week, which is under review.

According to the Uniform Assessment System (UAS), the patient's cognitive status is "Modified independence." She requires extensive assistance for bathing and lower body dressing. She requires only limited assistance for personal hygiene, bed mobility, toilet transfer/use. She is occasionally incontinent of bladder and continent of bowel. She uses a cane or walker with limited assistance for ambulation. This is an older patient who was recently hospitalized and underwent surgery for uterine cancer, and who is undergoing chemotherapy.

From a physical medicine and rehabilitation perspective, the requested Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 42 Hour(s) per Week is medically necessary.

Based on the above, the insurer's denial must be overturned. 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 42 Hour(s) per Week services is substantiated.