Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer/Breast Cancer. 
Treatment: Home Health Care. 

The health plan denied the requested increase in personal care assistant hours. 
The health plan's determination is overturned. 

The patient is a female with past medical history of schizophrenia, depression, anxiety, right breast cancer, insomnia, morbid obesity, hyperlipidemia, hypertension, osteoarthritis, and urinary incontinence who had 4 hours/day, 5 days/week of personal care assistant (PCA) services to total 20 hours/week based on a telephonic assessment tool performed assessing the patient at extensive assistance with tasks of meal preparation, ordinary housework, stairs, shopping, and transportation while limited assistance with tasks of managing finances, managing medication, equipment management, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use. With the task of phone use the patient was assessed at set up while independent with task of personal hygiene, dressing upper body, bed mobility, and eating. There was a request to increase PCA services, as the patient's significant other was returning to work in person, full time. The patient underwent another assessment, assessing the patient at total assistance with tasks of ordinary housework while maximum assistance with tasks of meal preparation, stairs, shopping, and transportation. With the tasks of bathing, dressing upper body, and dressing lower body, the patient was assessed at extensive assistance while limited assistance with tasks of managing finances, managing medication, personal hygiene, walking, locomotion, transfer toilet, and toilet use. With the task of bed mobility, the patient was assessed at supervision while set up assistance for phone use and independent with the task of eating. Notes from the assessment stated the patient used a quad cane or walker and her overall self-sufficiency had deteriorated in the last 90 days. The patient's primary care physician (PCP) provided a letter stating it was medically necessary for the patient to have an increase in PCA services to meet all of her personal care needs. The letter also stated due to her medical conditions the patient required assistance with ADLs including bathing, dressing, grooming, skin care, and meal preparation. In addition, the PCP letter stated the patient lived alone and had no formal support to provide her with assistance to meet her personal care needs on a regular basis and the patient had informal support, but her companion was not available during working hours. The patient's significant other provided a letter stating he was the patient's fiance and power of attorney. He noted in recent years due to the patient's diagnosis of breast cancer he had taken more responsibility for the patient's daily living and emotional needs and provides care for her in the evening, weekends, and overnight. The significant other also noted he worked full-time and early in the pandemic was allowed to telecommute every day but is now required to work in the office more often. His change in work schedule leads him to be away from home about 10-1/2 hours on each weekday and noted the patient was without any assistance on Fridays. Lastly, the significant other noted the patient needed assistance at home 5 hours/day. 

At issue is the medical necessity of the requested increase in personal care assistant hours. 

The health plan's determination of medical necessity is overturned, in whole. 

Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 5 hours/day, 5 days/week, to total 25 hours/week are medically necessary for this patient.