Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic Bladder Cancer.
Treatment: Home care/personal care HHC- level 2 personal care services increase to 24 hours per day (split shift).
The insurer denied home care/personal care HHC- level 2 personal care services increase to 24 hours per day (split shift).
The determination is overturned.

The requested services are medically necessary. The patient has a past medical history of hypertension, moderate to severe atherosclerosis disease, severe aortic stenosis status post aortic valvuloplasty, right breast cancer, thoracic (T) 6 compression fracture, hypothyroidism, osteoarthritis of hips/shoulders, unsteady gait, and metastatic bladder cancer who had been assigned personal care assistant (PCA) hours 8 hours /day, 7 days/week, to total 56 hours/week based on an assessment tool performed over the phone. The patient was assessed at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing medication, stairs, transportation, bathing, and dressing lower body. The patient was assessed at limited assistance with tasks of managing finances, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use while set up only with tasks of phone use and equipment management. With the tasks of bed mobility and eating the patient was assessed as independent. The patient is noted to live alone.
The patient had been diagnosed with bladder cancer and was hospitalized. She patient had an emergency department (ED) visit with a complaint of back pain. She had an office visit with her medical oncologist  noting the patient was moribund and had a substantial decline in performance status with the recommendation to set up home hospice as soon as possible and there was a request to increase PCA hours. The patient had a telephonic assessment tool performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and shopping while maximum assistance with tasks of stairs. The patient was assessed at extensive assistance with tasks of managing medication, phone use, transportation, bathing, personal hygiene, and dressing upper/lower body while limited assistance with tasks of walking, locomotion, transfer toilet, toilet use, and eating. With the tasks of phone use and equipment management, the patient was assessed at supervision while independent with task of bed mobility.
The plan sent a final adverse denial determination notice stating the request was not medically necessary and did not meet criteria further stating the patient has a past medical history of arthritis with no loss of motor function noted. The denial letter stated most of the patient's physical functioning did not change from the  prior assessment and hours beyond the current amount would be for safety monitoring which is not a covered benefit but did increase PCA hours to 70 hours/week. The patient's oncologist wrote a letter stating that she has rapidly deteriorating Stage IV metastatic bladder cancer, severe to moderate atherosclerotic disease, osteoarthritis of her hips, severe T6 compression fracture, and had a pelvic fracture after a fall in her home.
When seen in the oncologist's office, the patient had significant clinical and functional decline. The letter further stated the progressive nature of her illness has led to extreme weakness, fatigue, and pain. In addition, the oncologist's letter stated the patient requires assistance performing all of her activities of daily living (ADLs) including walking, transferring, toileting, and repositioning in bed and the current plan of care of ten hours per day is insufficient to meet her ADL needs. The letter also noted that the patient is unable to walk with a walker independently, does not have the strength to transfer independently, has a urostomy bag which needs to be emptied every 2-4 hours and she is unable to empty on her own, and due to her weakness and history of thoracic compression fracture has limited ability to reposition herself in bed. The letter also stated the patient needed an aide to be present to assist in turning and positioning in bed every two to four hours in order to keep the patient's skin intact and prevent pressure ulcers and would need 24 hour care with aides working two twelve hour shifts. The patient's health care advocate provided a letter initiating an expedited external appeal on behalf of the patient stating the historical data above and that the patient had a prognosis of less than three months to live. The letter also stated the patient needs hands on assistance with medication administration and takes pain medication in the overnight hours. At issue is the medical necessity of home care/personal care home health care (HHC)- level 2 personal care services increase to 24 hours per day (split shift).
The patient had documented progression of her Stage IV bladder cancer with a poor prognosis and decline in functional status. The patient also has a documented T6 compression fracture and osteoarthritis. The patient did have a change in her assessment with the tasks of meal preparation, ordinary housework, managing finances, phone use, stairs, shopping, equipment management, personal hygiene, dressing upper body, and eating. The assessment underestimated the patient's care needs for walking, locomotion, transfer toilet, toilet use, and bed mobility as documented in the attending physician's notes and letters. The patient has a urostomy bag which requires emptying every 2-4 hours and the patient is unable to do this without assistance. The attending physician recommended that the patient have turning and repositioning every 2-4 hours and the patient is unable to reposition herself in bed independently. The patient requires prompting and assistance with medication in the overnight hours. The patient has overnight needs that would not allow a PCA to obtain 5 hours of uninterrupted sleep thereby needing two-12 hours shifts. The nature of the patient's current medical diagnosis and prognosis would progressively increase her need for assistance with all ADLs/instrumental activities of daily living (IADLs). The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/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, 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 her own home.