Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Merkel cell carcinoma

Treatment: personal care services, per 15 minutes increase to 24 hours per day (split shift)

The insurer denied coverage for personal care services, per 15 minutes increase to 24 hours per day (split shift).

The denial is overturned.
 

This elderly patient is diagnosed with end-stage cancer (Merkel cell carcinoma of the eye and face that is no longer treatable), cognitive, visual, and hearing impairments, vertigo, bowel and bladder incontinence, and anxiety disorder (on daily Ativan). He has facial deformity from the cancer and dysphagia requiring a soft mechanical diet. He is described in the attached assessment forms as "frail elderly" with "moderate fatigue" that does not allow him to finish day to day activities. He requires moderate to maximum assistance for transfers and activities of daily living. He is largely dependent upon a wheelchair for mobility. He lives alone and is a high fall risk, with rapidly worsening functional status. In summary, he has a grim prognosis and life expectancy that would likely qualify him for immediate hospice placement. His oncologist documented that the patient should consider transitioning to hospice/palliative care.

The patient needs 24/7 skilled caregivers. It is not in the best interest of the patient to reduce his caregiver hours at this time, as his condition is worsening, and he is at risk for injury, severe bleeding, and death without constant monitoring.      

Level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift) is considered medically necessary for this patient. 

According to the Final Adverse Determination Denial Notice, the insurer determined that the increase in caregiver hours was not medically necessary based upon a Uniform Assessment System (UAS) tool but did not give the date of the tool reviewed. There are two provided to this reviewer. The review did not take into account more recent clinical notes from the patient's oncologist as part of the determination. These notes clarify that the patient's health is rapidly declining and that hospice/palliative care are being considered. The patient clearly needs 24/7 care (it is medically necessary). He is a high fall risk and has friable facial tissue that bleeds easily and potentially heavily if not tended to.

As such, the patient should receive the maximal allowable home care services.

"When friends and family are unavailable or unable to care for homebound loved ones, primary care often deploys Home and Community-Based Services, including home health aides. For these homebound older adults, home health aides are essential to help preserve an independent life at home and avoid nursing home care" (D'Cruz, L., et al.).

"Millions of older adults and adults with chronic conditions and disabilities in the United States depend on home care workers to remain at home and age in place. Home care workers, which include home health aides, attendants, and personal care aides, provide assistance with personal care (activities of daily living and instrumental activities of daily living), medically oriented care, and emotional support" (Shaw, A. L., et al.). 

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 Level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift) is substantiated.