Diagnosis: chronic back pain with a moderate decrease in range of motion and severe ambulation impairment

Treatment: home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week

The insurer denied coverage for home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week

The denial is upheld.


This case involves an elderly patient with multiple diagnoses consisting of polyarthritis, chronic pain, hypertension, chronic ischemic heart disease, chronic systolic congestive heart failure, generalized muscle weakness, abnormalities of gait and mobility, urinary incontinence, urge incontinence, muscle spasm, spinal stenosis, left side sciatica, chronic kidney disease, dizziness and giddiness, fatigue, atrial fibrillation, atherosclerotic heart disease, morbid severe obesity with alveolar hypoventilation, and major depressive disorder. The documentation provided for the review stated that the patient lives alone and required assistance with instrumental activities of daily living (IADL)and activities of daily living (ADL) to include cooking, housework, bathing, transfers, dressing, and personal hygiene. The tasking tool noted the patient required assistance with multiple activities with a total weekly time for service calculated at 36.83 hours. The patient was receiving personal care services 49 hours per week and was requesting an increase to 84 hours per week. The treating physician stated that the patient was suffering from multiple progressive chronic medical problems to include chronic back pain with a moderate decrease in range of motion and severe ambulation impairment. The patient also was status post left shoulder surgery, had impaired vision, status post bilateral cataract surgery. He had lower extremity edema, muscle cramps, arthralgia, arthritis/arthrosis affecting multiple joints with moderate pain, decreased range of motion, along with hypertension, severe dyspnea on exertion, prediabetes, urinary incontinence, and morbid obesity. The patient uses a walker and needs human assistance with minimal physical activities. This was for his safety and wellbeing, thus the recommendation for increase to at least 12 hours 7 days a week.

The request for an increase in hours was denied. The report stated that the review of the patient's physical functioning since the prior assessment was relatively unchanged. Additionally, the patient had no impairments in terms of memory, and while he had reports of bladder incontinence, there was no bowel incontinence in the current personal care services were sufficient in addressing the needs of the patient. This review pertains to the denial of coverage for home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week.

Literature notes that personal assistant services/personal care services allow patients to remain in their home rather than receiving treatment/care in a long-term acute care facility or a nursing home/skilled nursing setting. The documentation provided for the review noted that the patient had a history of multiple conditions and was receiving personal care services 49 hours/week. While there are reports of some changes in the patient's condition, they were not substantial enough to require a significant increase in personal care service hours at this time.

Based on the above, the insurer's denial must be upheld. The health care plan did 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 is not substantiated.