Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, hypertension and metastatic rectal cancer.
Treatment: Home care / personal care HHC (home health care)- Level 2, personal care services, per 15 minutes, increase to 24 hours per day, split shift.
The insurer denied coverage for home care / personal care HHC - Level 2, personal care services, per 15 minutes, increase to 24 hours per day, split shift.
The denial is overturned.    

This is an elderly patient with medical problems including diabetes, hypertension and metastatic rectal cancer. She is currently residing in a nursing facility after being hospitalized secondary to a fall. She has a nephrostomy tube for urine collection and a gastric tube for feeding. The patient will be living alone upon returning home. The daughter-in-law will be the primary personal aide for Consumer Directed Personal Assistance Service (CDPAS). The insurer approved Consumer Directed Personal Assistance Service (CDPAS) 24 hours/day (live-in) and the request is for CDPAS 24 hours a day, 7 days a week (split shift); which is currently under review. 

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times."  She is totally dependent for much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping. She is also totally dependent for bathing, lower body dressing and toilet use. Maximal assistance is needed for personal hygiene, upper body dressing, locomotion and eating. Extensive assistance is needed for toilet transfer and ambulation. Limited assistance is needed for bed mobility. She has pressure ulcers at the sacrum and the heel. The patient has a nephrostomy tube for urine collection and is frequently incontinent of bowel. She has multiple episodes of diarrhea due to the rectal cancer.  

The patient's functional ability has significantly declined when compared to the UAS. The patient is a frail (77 pounds, 5' (feet) 2" (inch), elderly patient with terminal metastatic rectal cancer. Her medical condition and functional ability are at a level or unpredictable as to require the requested CDPAS 24 hours a day, 7 days a week (split shift). The option of a live-in CDPAS is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain an uninterrupted 5 hours of sleep. Of particular concern are the patient's pressure ulcers and the need for repositioning while in bed with a frequency of at least every 2-3 hours. In addition, she has a nephrostomy tube that is routinely infected and requires at least daily dressing changes. She also requires a percutaneous endoscopic gastrostomy (PEG) tube for feeding. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained at home with CDPAS 24 hours a day, 7 days a week (split shift).

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 home care / personal care HHC - Level 2, personal care services, per 15 minutes, increase to 24 hours per day, split shift is substantiated.