Diagnosis: Osteoarthritis, Hypertension, Heart failure
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services (PCS), per 15 minutes Increase to 84 Hour(s) per Week.
Denied: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 84 Hour(s) per Week.
The insurer decision is overturned.

This is an elderly patient with medical problems including hypertension, heart failure and osteoarthritis. He is also legally blind and hearing impaired. He lives alone in an apartment. His daughter lives with her spouse upstairs in the same dwelling. He is approved by the insurer for PCS 70 hours/week and the request is for 84 hours/week.

According to the recent Uniform Assessment System (UAS) report, the patient's cognitive status is described as "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times." He requires maximal assistance for bathing, personal hygiene, lower body dressing and toilet use. Extensive assistance is needed for upper body dressing, locomotion, ambulation and toilet transfer. He is frequently incontinent of bladder and continent of bowel. The patient's condition and functional needs are a level or unpredictable as to require the requested personal care services (PCS) 12 hours/day, 7 days/week. Based on the enclosed documents reviewed, the patient's health and safety is more appropriately provided and maintained at home with the requested PCS 12 hours/day, 7 days/week, totaling 84 hours/week.

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.

From a physical medicine and rehabilitation perspective, home care / personal care (HHC) - level 2 PCS, per 15 minutes increase to 84 hours per week is medically necessary.

Based on the above, the insurer's denial must be reversed. 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 services is substantiated.