Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intrahepatic bile duct carcinoma. 
Treatment: Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week. 
The insurer denied Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week. 
The determination is overturned. 

This is a male patient with a medical history notable for intrahepatic bile duct carcinoma and dementia. The patient is currently residing in a skilled nursing facility and his care team is attempting a discharge home. He was approved for 9.5 hours per day, 7 days per week (66.5 hours per week) of personal care aide level 2 services. The patient's care team requested an increase to 24 hour per day split-shift personal care, 7 days per week (168 hours per week) and the request was denied by the health plan. 
The patient's hospice social worker provided a letter of support for this appeal. The letter states that the patient is terminally ill from intrahepatic bile duct carcinoma with an expected life expectancy of six months or less. He needs total assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL) and is mostly bedbound. He is nonverbal and unable to direct his own care. He is currently living in a nursing facility. His family lives out of state and cannot assist with care. He has a neighbor in his building that has volunteered to assist with medication management (as home health aides are not permitted to administer medication). 
Hospice nurse notes were provided for review. Pressure reduction measures were recommended for the patient, including reposition and turn at least every 2 hours. He did not have any evidence of skin breakdown as evidenced by this care being provided in the nursing facility. 
A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert but non-verbal and unable to interact; cognition was impaired. For Instrumental activities of daily living (IADL), the patient requires total dependence for essentially all. For his activities of daily living (ADL's), the patient requires total dependence or maximal assistance for all. He is bed bound and cannot direct his care; the nursing facility staff assists with all activities and directs care. He did not have any skin breakdown. He was frequently incontinent of stool and urine and wears diapers/chux pads for episodes of incontinence. At issue is the medical necessity of Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week. 

The requested health service of Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week is medically necessary for this patient. 
The patient is receiving end-of-life hospice care. His dementia is advanced to the point of being nonverbal. He is not able to complete any ADLs or IADLs without human assistance, including bed-mobility. He must be turned and repositioned every 2 hours throughout the day and night to prevent skin breakdown. He is frequently incontinent of stool and urine and cannot direct his own diaper changes; he will require frequent checking and changes throughout the day and night. By definition, the patient's care needs are expected to be continuous and unscheduled throughout the day and night. Therefore, the requested increase to 24 hour split-shift personal care is medically necessary and reasonable for the patient.