Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer 
Treatment: Home Health Care 
The insurer denied increase in personal care assistance hours to 30 per week. 
The denial is overturned.

The patient is a female with past medical history of anxiety, depression, hyperlipidemia, hypertension, gastroesophageal reflux disease (GERD), hypothyroidism, glaucoma, venous insufficiency and a recent diagnosis of breast cancer. The patient had been assigned Personal Care Assistance (PCA) hours based on an assessment tool performed via telephone assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs, transportation, bathing, and dressing lower body. The patient was assessed at limited assistance with tasks of managing finances, managing medication, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and eating while set up for phone use and was independent with bed mobility. A summary of hours from tasking tool calculated 17.24/week. There was a request to increase PCA hours and the patient underwent a telephonic assessment tool assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, stairs, transportation, bathing, dressing lower body, and toilet use while limited assistance with tasks of equipment management, personal hygiene, dressing upper body, walking, locomotion, and transfer toilet. With task of phone use the patient was assessed at set up only while independent with tasks of bed mobility and eating. Notes from telephonic assessment noted the patient had no informal helper, but did live in a private home with a child. The notes also stated the patient had a recent diagnosis of breast cancer and her overall self-sufficiency had deteriorated. A summary of hours from tasking tool totaled 18.6 hours/week. The subject under review is the medical necessity for increase to 30 hours per week.

The health plan's determination is overturned in whole.

The request for Personal Care Assistance Services, Level II, 6 hours per day, 5 days per week, for a total of 30 hours per week is medically necessary. The patient has documented worsening of functional status related to her recent diagnosis of breast cancer and subsequent chemotherapy and radiation treatment. The patient's medical provider recommended increased PCA hours to help reduce anxiety, complete daily tasks, and improve functionality in the home. The patient requires extensive assistance with task of toilet use, which is an unpredictable and unscheduled care need. The assessment stated the patient did not have an informal helper and therefore would need assistance outside the hours she does have help from family. The insurer recommended the patient follow up with her doctor regarding the symptoms she was reporting and see her doctor to find out what is happening with her health, yet the patient's provider has been actively monitoring and following the patient with recommendation to increase PCA services. The requested increase in PCA services is not solely for safety and supervision, but to assist the patient with safe completion of activities of daily living (ADLs)/instrumental activities of daily living (IADLs). Taking into account the information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 6 hours/day, 5 days/week, to total 30 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.