Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancreatic Cancer
Treatment: Home Health Care
The health plan denied the requested increase in PCA hours as not medically necessary. The health plan's determination is overturned.

The patient is a female with a past medical history of coronary artery disease, pancreatic cancer, osteoporosis, hypertension, osteoarthritis, hearing loss, gastroesophageal reflux disease (GERD), rheumatoid arthritis, age-related cognitive decline, and urinary incontinence who had been assigned to the consumer directed personal assistance program (CDPAP) services 45 hours/week based on assessment tool performed, assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and stairs while maximum assistance with tasks of managing finances, shopping, transportation, bathing, and dressing lower body. With tasks of managing medication, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility, the patient was assessed at extensive assistance, while limited assistance with tasks of phone use and eating. 

There was a request to increase CDPAP services and the patient underwent an assessment tool, assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, and shopping while maximum assistance with tasks of managing medication, transportation, bathing, and toilet use. With tasks of phone use, personal hygiene, dressing upper body, walking, locomotion, and transfer toilet, the patient was assessed at extensive assistance, while limited assistance with tasks of bed mobility and eating. 

The health plan's determination is overturned, in whole.

Yes, there is documentation of worsening physical and cognitive functioning following coronary artery bypass graft (CABG) surgery and pancreatic cancer treatment with hospitalizations. The patient's medical providers have recommended an increase in CDPAP services. When comparing assessments, the patient did have an increase in assistance needs with managing finances, managing medication, phone use, shopping, toilet use, and bed mobility. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 that occur when the patient does not have informal help. 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, CDPAP services 70 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 her own home.