Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Metastatic Oral Cancer, Dementia.
Treatment:  Coverage for 7 days per week, 24 hours per day; continuous care by more than 1 person; 168 hours per week; Level 1 PCW Services.

The insurer denied the coverage for 7 days per week, 24 hours per day; continuous care by more than 1 person; 168 hours per week; Level 1 PCW Services.  The denial was overturned.

This is a female patient who has multiple medical conditions including prolonged course of treatment for oral cancer with metastatic disease (s/p surgery, radiation, chemotherapy).  As a result of surgical removal of part of her jaw, oral intake had declined and patient had PEG placed in early 2020 for nutrition, hydration and medications.  Other chronic conditions include dementia, osteoarthritis, and incontinence.  As a result of these conditions, the patient has substantial functional impairment for IADLs and ADLs, requiring caregiver assistance.  The patient was approved for personal care worker (PCW) services 56 hours per week. 

The patient has h/o squamous cell carcinoma of skin, impaired swallowing with recent PEG placement due to inadequate nutrition, age related cognitive impairment, insomnia, h/o UTI with change in mental status, osteoarthritis, fatigue, gait disturbance, chronic pain, stress incontinence, weakness, dizziness repeated falls with injury and hospitalizations.  Patient needs maximal assistance with transfers, ambulation, toileting, incontinence care, dressing throughout the day and night. 24 hour live-in personal care assistance is medically necessary.  Under no circumstances should she transfer without hands-on assistance.  Patient has a history of urinary tract infections and  incontinence must be addressed immediately; she should not stay in soiled diaper, which can lead to infection.

The patient has diagnosis of dementia; no formal medical evaluation is available.  The UAS reports patient's decision-making capacity for daily tasks is consistently poor or unsafe; patient has memory impairment, and report from daughter indicates that dementia is getting worse with increased confusion at night.  Functional decline of daily activities is an expected consequence of dementia as the disease progresses with loss of ability for IADLs usually occurring before decline of ADLs.  With patient's poor decision making skills and impaired memory, it is likely that cognitive impairment is a factor in the decline of the patient's ability to perform IADLs. 

The patient is frail, with recent h/o cancer, dependent on PEG feedings, and has multiple symptoms that cause discomfort and have adverse effects on her functional ability.  Included in the goals for her care is to minimize risk for further adverse health and safety events, including, falls/injuries, infection, skin injury.  She has had extensive help from her children, including care at night.  Both children work, but have been more available recently due to COVID-19.  It is noted that the son (with whom she lives) is disabled, and it is not clear whether this limits his ability to help his mother.  When both children are working, it is not possible for son or daughter to attend to their mother for all the hours of the day and night after the PCW leaves each day.  It was noted that other arrangements will be made for tube feedings when the daughter returns to work (PCW does not provide this service). 

Based on the above, the medical necessity for 7 days per week, 24 hours per day; continuous care by more than 1 person; 168 hours per week; Level 1 PCW Services is substantiated.  The insurer's denial is overturned.