Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Giloblastoma multiforme.
Treatment: increase in personal care assistance services from 7 days x 24 hours live in per week to 7 days x 24 split shift hours per week.
The insurer denied increase in personal care assistance services from 7 days x 24 hours live in per week to 7 days x 24 split shift hours per week.
The determination is overturned.
 

The patient has a past medical history of glioblastoma multiforme, grade IV(Intravenous), normal pressure hydrocephalus, sacral decubitus ulcer, insomnia, and sundowning/agitation who was been assigned personal care assistant (PCA) services, 24 hours/day, live-in, 7 days/week. There was a request to increase PCA services and the patient underwent an assessment tool  assessing the patient at total assistance with all tasks except managing medication for which she was assessed at maximum assistance. Notes from the assessment stated the patient lived alone and had no informal help.

The insurer sent a final adverse determination denial notice denying request to increase PCA services stating it was not medically necessary and there was no medical need reported that a split-shift aide was necessary. Lastly, the denial stated the plan was not required to provide personal care assistance services for safety supervision alone. The patient's daughter appealed the denial decision with a letter stating the patient had been diagnosed with stage IV glioblastoma, loss of movement of right arm and leg, loss of movement on the left side following chemotherapy and radiation, was confined to her bed, and had developed a stage 3 pressure ulcer on her sacrum. The daughter's letter also stated the patient must be rotated side to side every one to two hours to relieve pressure from the decubitus ulcer. The daughter also noted that she and her brother were providing night time care for the patient which was unsustainable due to the daughter's and son's routine full time jobs.

The patient's physician appealed denial decision writing a letter stating the patient had ongoing insomnia, delirium, and agitation related to glioblastoma multiforme. The provider noted the patient had unusual and unpredictable sleep/wake patterns that made it difficult for her caretakers to manage her at home and the patient would benefit strongly from 24 hour split shift for home care.

At issue is the medical necessity of increase in personal care assistance services from 7 days x 24 hours live in per week to 7 days x 24 split shift hours per week.

The services are medically necessary. There is documentation of the patient's functional and mental decline following treatment for glioblastoma with resultant decubitus ulcer and delirium and agitation. The patient's primary care physician (PCP) noted the patient would benefit from 24 hour split shift home care. The patient requires total assistance with all tasks except managing medication. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient has overnight care needs with the need to have turning and repositioning every 1 to 2 hours with sacral decubitus ulcer and frequent changing of soiled diapers to prevent further skin breakdown. A PCA would not be able to obtain at least 5 hours of uninterrupted sleep due to the patient's overnight care needs. The requested increased in PCA services was not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) /instrumental activities of daily living (IADLs). 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 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 her own home.