Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cancer. 
Treatment:  Home Health Care. 

The insurer denied consumer directed personal assistance services.  The health plan's determination is overturned in whole. 

The patient is a female with past medical history of Mulvihill-Smith syndrome, bilateral hearing loss, bilateral vision impairment with keratoconus, mild intellectual impairment, hypertension, diabetes mellitus (DM) type 2, hypothyroidism, spinal hemangioma, iron deficiency, hypertriglyceridemia, pancreatic insufficiency, and hepatocellular cancer, who applied for personal care assistance (PCA) services.  The patient is on a list for liver and pancreatic transplant. 

The patient's hepatologist provided a letter stating the patient's progressive medical condition, which impacts her functioning and ability to care for herself due to frequent fatigue.  The patient has strict dietary needs due to DM type 2 and hypertriglyceridemia.  The patient has diffuse melanocytic nevi requiring proper dressing to cover all skin.  The patient has multiple medical visits with various subspecialists requiring assistance and takes multiple medications requiring help from caretaker.  Specifically, the provider states the patient requires assistance with housekeeping, food shopping, cooking, medications, attending medical appointments, and monitoring symptoms.  The provider summarizes with the following statement, "The patient's condition is unique and complex.  Her functioning is limited by her intellectual disability, her vision and hearing impairments, and many complications caused by her disease.  Her condition may worsen with time.  She requires personal care services in order to remain safely at home and minimize risk of unnecessary hospitalizations." 

The health plan's determination is overturned in whole. 

The Consumer Directed Personal Assistance Services are medically necessary for this patient.  The patient has documented progressive medical diagnoses with short stature, vision impairment, hearing impairment and intellectual disability with diagnosis of hepatocellular cancer with ongoing active treatment.  The patient is being considered for pancreas and liver transplant.  The patient's medical providers have cited medical necessity of Personal Care Assistance (PCA) services to assist patient with ADLs and IADLs with the likely need for increased help as her disease progresses and/or with pancreas/liver transplant. 

The Uniform Assessment System (UAS) completed noted the patient requires assistance with tasks of meal preparation, ordinary housework, and shopping and some assistance with tasks of managing medication, managing finances, phone use, stairs, transportation, and equipment management.  The UAS underestimated the patient's care needs for bathing, personal hygiene, walking, locomotion, transfer toilet, and toilet use, as she does have periods of time with increased fatigue requiring support and assistance, as she continues to undergo active treatment for hepatocellular cancer.  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.