Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatocellular Carcinoma
Treatment: Home Health Care
The health plan denied the request for an increase in personal care assistant hours. 
The health plan's determination is upheld.

The patient is a female with a past medical history of hepatocellular carcinoma, cerebrovascular accident (CVA), osteoarthritis, glaucoma, hearing loss, hypertension, hyperlipidemia, coronary artery disease, multiple myeloma, Alzheimer's dementia, urinary incontinence, bowel incontinence, and diabetes mellitus type 2 who had been assigned personal care assistant (PCA) services 7 hours/day, 7 days/week to total 49 hours/week based on an assessment tool performed. The patient was assessed at total assistance with tasks of meal preparation, ordinary housework, and shopping while assessed at extensive assistance with tasks of managing medication, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at limited assistance with tasks of managing finances, phone use, bed mobility, and eating.

The patient's primary care physician (PCP) provided a letter stating the patient's diagnoses of Alzheimer's disease, ataxia with frequent falls and hospitalizations, episodic psychosis and confusion due to liver insufficiency with high ammonia levels needing home aide help 12-15 hours/day. The patient was hospitalized with hepatic encephalopathy, acute kidney injury, right cerebellar infarct and presumed spontaneous bacterial peritonitis with treatment with hemodialysis and intravenous (IV) antibiotics. The patient's hepatologist provided a letter stating the patient's diagnoses of non-alcoholic steatohepatitis (NASH), hepatocellular carcinoma, and new liver decompensation. The provider noted deterioration of the patient's physical stamina and increased episodes of encephalopathy which put her at higher risk of falls, accidents at home, and improper medication administration. This provider is requesting an increase of home health aide hours for additional supervision and assistance at home. The hepatologist's letter further stated " due to her age and these comorbidities, the patient needs daily assistance with medication supervision, daily activities, and personal care. Additionally, the patient must follow a strict diet and requires assistance with food preparation. Please reconsider the patient's request for additional home health hours for all reasons stated above".

The health plan's determination of medical necessity is upheld.

No, the requested services are not medically necessary.
The patient has documented worsening of Alzheimer's dementia, physical stamina and needs assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). However, there is not sufficient documentation or evidence in records that the patient has overnight care needs that would not allow a PCA to obtain at least five hours of uninterrupted sleep. There was no documentation that the patient requires turning and repositioning every 2 hours which would also not allow a PCA to obtain five hours of uninterrupted sleep as well. An assessment tool documented that the patient had become more agitated and confused and was found wandering in the hallway on one occasion. PCA service hours are not for companionship and safety supervision but to assist the patient with completion of ADLs and IADLs. It is not medically necessary for patient to have split shift 24 hours PCA services.