Diagnosis: Generalized weakness, fatigue and osteoarthritis

Treatment: home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 42 hours per week

The insurer denied coverage for home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 42 hours per week

The denial is overturned


This is an elderly person with generalized weakness, fatigue and osteoarthritis. He lives with a friend. He currently has personal care services (PCS) from Mondays to Fridays totaling 30 hours/week. The patient is requesting an increase in PCS hours from 30 to 42 hours/week to include Saturdays and Sundays.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as modified independent. He reportedly requires extensive assistance to total dependence for much of his Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping. He reportedly requires extensive assistance for bathing, lower body dressing and toilet use. Limited assistance is needed for personal hygiene, upper body dressing, locomotion, toilet transfer and ambulation. The patient is independent with bed mobility and eating. He is frequently incontinent of bladder and continent of bowel.

The patient's functional ability has decreased when compared to the previous UAS report. The patient's condition and functional deficits are at a level or unpredictable as to support an increase PCS from 5 days/week totaling 30 hours to 7 days/week totaling 42 hours. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing home care/ personal care HHC - level 2 PCS, per 15 minutes to 42 hours per week.

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 hours per week is substantiated.