Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer
Treatment: Home Health Care

The insurer denied an increase in PCA services to 7 days x 24 hours (split-shift) continuous care services. 

The denial was overturned. 

The patient is a male with past medical history of constipation, gastroesophageal reflux disease (GERD), major depressive disorder, macular degeneration, prostate cancer, Parkinson's disease, urinary incontinence, and stage 4 (IV) urothelial carcinoma who had been assigned personal care assistance (PCA) services 24 hours/day, live-in, 7 days/week. The patient's oncologist provided a letter stating the patient was under his care and had metastatic urothelial carcinoma with a prognosis of less than 6 months without treatment and as such would require additional assistance. The insurer provided a letter noting the review for requested increase in PCA services was extended as there was not enough information to make a favorable decision and the insurer needed physicians order which documented a medical condition and frequency for the patient's nighttime needs as well as an updated universal assessment screen. 

The patient's urologist provided a letter stating the patient had a history of bladder cancer, had voiding complaints for which he had taken medication for years, and had Parkinson's disease making it difficult for him to get to the bathroom independently. The PCP letter stated the patient was not able to properly feed himself and was unable to gain weight. The patient's primary care provider (PCP) recommended 24-hour care to assist the patient with daily living and personal hygiene. Lastly, the PCP noted the patient should be frequently turned and repositioned to help to pressure offload his weightbearing surfaces in order to prevent further breakdown and potential sequelae of pressure wounds. 

At issue is the medical necessity of Increase in personal care assistance (PCA) services from Live-in 24-hour care to 7 days x 24 hours (split-shift) continuous care services. 

The health plan's determination of medical necessity is overturned in whole. 

The requested health service/treatment of Increase in personal care assistance (PCA) services from Live-in 24-hour care to 7 days x 24 hours (split-shift) continuous care services is medically necessary for this patient. 

There is documentation of patient's terminal stage IV urothelial carcinoma with increase in urinary urgency during the day and nighttime hours. The patient has since developed a sacral ulcer and his PCP recommended the patient be turned and repositioned frequently to help to pressure offload weightbearing surfaces and to prevent further breakdown of skin and pressure wounds. Therefore, the patient's primary care provider supplied a medical condition that directly caused the patient to need assistance throughout the day and night with such frequency that a live-in personal care assistant would be unable to provide the required care. Due to the patient's frequent urinary urgency/frequency related to metastatic bladder cancer and the need for frequent turning and repositioning a PCA would not be able to obtain at least 5 hours of uninterrupted sleep. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are 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 his own home. 

Therefore, the requested service of Increase in PCA services from Live-in 24-hour care to 7 days x 24 hours continuous care services is medically necessary.