Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Home Health Care. 
The insurer denied increase in personal care aide hours to 7 days x 24 hours (split shift). 
The denial is overturned.

The patient is a female with past medical history of metastatic breast cancer, osteoarthritis, memory loss, gastroesophageal reflux disease (GERD), and hypothyroidism who had Personal Care Assistance (PCA) services for several years. During the Covid-19 pandemic the patient's family requested a reduction in PCA hours due to concern over exposure. Case notes from insurer stated the patient was never left alone and was getting more forgetful and weaker. The patient's regular aides refused to come to work due to Covid crisis and the family continued to not want replacement aides. The Case notes from the insurer stated the patient's walking was declining and the son had interest in being the member's Consumer Directed Assistance Services (CDPAS) worker until regular aides returned to service. The subject under review is the medical necessity for personal care aide 7 days x 24 hour (split shift) for this patient.

The health plan's determination is overturned. 

The patient has documented progressive worsening of functional status related to metastatic breast cancer. The patient also has underlying progressive disorder of osteoarthritis with worsening mental status with increased agitation and confusion. The patient's functional status and mental status has worsened since her last telephonic assessment. Furthermore, this assessment performed showed an improvement in her assessment needs compared to the prior one, with tasks of bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and eating and therefore underestimated her assistance needs even at that time. There is documentation the patient requires assistance with all activities of daily living (ADLs) and frequently uses the bathroom in the overnight hours requiring such assistance. The assistance the patient would require in the overnight hours would not allow a personal care aide  5 hours of uninterrupted sleep. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). The patient has unscheduled and unpredictable care needs over a continuum of time. Due to her increased agitation over the last month the patient requires increased assistance with her ADLs. The insurer stated in their denial letter criteria had not been met because there were no documented changes to her environmental surroundings, social status or functional abilities, when there had been significant changes to her functional abilities due to the progression of her cancer.
Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal care Aide 7 days x 24 hours (split shift) is 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.