Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stage 4 colorectal cancer
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day 5 days per week; Personal Care Aide (PCA) Level 2: 12 hours per day 2 days per week a combined total of 84 hours per week
The insurer denied CDPAP: 12 hours per day 5 days per week; Personal Care Aide (PCA) Level 2: 12 hours per day 2 days per week a combined total of 84 hours per week.
The determination is overturned. 

This is a female with a medical history notable for dementia, incontinence, congestive heart failure, and cancer. The patient was approved for 7 hours per day, 7 days per week for a total of 49 hours per week of personal care assistance. The patient and her care team requested an increase in hours.
The patient's son provided a letter of support for this appeal. The letter states that the patient has stage 4 colorectal cancer and breast cancer, and that they were recently informed that her treatments are no longer working for her. He stated that the patient is in a weakened condition and needs assistance with all personal care tasks. Specifically, she requires assistance with toileting, ambulation, and transfers. Her family is supportive but cannot provide 24-hour care. He stated that there are currently gaps in her care where she must be left alone without her assistant or a family member and the request for additional hours is to allow these gaps to be covered. He stated that she is currently bedridden and requires around the clock care.
The patient's physician provided a letter for this appeal. The letter stated that the patient has breast and colon cancer which has metastasized to her liver, bones, and lymph nodes. She has had a notable functional decline with decreased mobility. She requires assistance for eating, toileting, and other personal care tasks. The physician stated that the increase in care hours is medically necessary for the patient.
A Uniform Assessment System was completed. The patient lives alone in a one-bedroom apartment. She was alert and oriented but forgetful with a history of dementia. Her recall was one out of three after 5 minutes. For her instrumental activities of daily living, the patient requires total dependence for housework. She requires maximal assistance for transportation, shopping, stairs, managing medications, and meal preparation. For her activities of daily living, she requires maximal assistance for bathing, dressing lower body, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, and bed mobility. She is frequently incontinent of urine and occasionally incontinent of stool.

The requested health service of (CDPAP): 12 hours per day 5 days per week; Personal Care Aide (PCA) Level 2: 12 hours per day 2 days per week a combined total of 84 hours per week is medically necessary for this patient.
The patient requires hands-on caregiver assistance for all activities of daily living, including transfers, ambulation, toileting, and incontinence care. Her family is involved and supportive but cannot provide 24-hour care. She has multiple letters which attest to the need for additional assistance during the hours when she would otherwise be left alone. Therefore, the requested increase to 12 hours per day is medically necessary for the patient. This will allow her to have adequate coverage for her unscheduled personal care needs such as toileting and incontinence care. Failure to provide for her personal care needs could result in infection, skin breakdown, and or injury.