Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Breast Cancer.
Treatment:  Personal Care Services, 5 hours a day, 5 days a week for a total of 25 hours per week.

The insurer denied Personal Care Services, 5 hours a day, 5 days a week for a total of 25 hours per week.  The determination is overturned.

The patient has a past medical history of metastatic breast cancer, neuropathy, urinary incontinence, bowel incontinence, coronary artery disease, chronic dizziness, hearing loss, fall risk, and chronic pain related to bony metastasis, who had been assigned personal care assistant (PCA) services 5 hours/day, 3 days/week, to total 15 hours/week.  The patient's medical provider provided a letter stating the patient's current diagnoses while also requesting an increase in home attendant hours.  The provider also noted the patient's symptoms of fatigue, nausea, chronic low back pain, dizziness, poor balance, and neuropathy in her fingers.  In addition, the letter stated the patient had fallen multiple times without her home attendant and requires a wheelchair outside of the home and needs accompaniment out side of the home and assistance with medical transport.  Lastly, the medical provided documented that the patient's  spouse was not able to provide informal care.  A social worker from the patient's cancer center provided a note requesting an urgent increase in home attendant hours, and the patient has advanced metastatic cancer and needs additional hours for assistance at home and to accompany to medical appointments.  There was a request to increase PCA hours to 5 hours/day, 5 days/week, to total 25 hours/week.  The patient had a telephonic assessment tool performed assessing the patient at maximal assistance with tasks of ordinary housework and shopping while extensive assistance with tasks of meal preparation, managing finances, managing medication, stairs, and transportation.  The patient was assessed at limited assistance with tasks of bathing, dressing upper/lower body, walking, and locomotion while set up only for phone use.  Lastly, the patient was assessed as independent with tasks of transfer toilet, toilet use, bed mobility, and eating.  The plan sent a final adverse determination denial notice stating the service is not medically necessary, and the patient did not meet criteria for increase in PCA services.  The denial further stated the plan can provide in-home physical therapy to increase her safety and that giving more hours cannot prevent falls and injuries.  In addition, the denial letter stated PCA hours are not for safety supervision, companionship or when there are no tasks being done.  The plan further listed the equipment and supplies the patient has in her home.  PCA services were increased to 5 hours/day, 3 days/week, and 2 hours/day, 2 days/week, to total 19 hours/week.  The patient had an office visit with oncology provider stating the patient was receiving chemotherapy, has persistent dizziness, takes morphine immediate release (IR) for generalized arthralgias, takes Lyrica for neuropathy, and noted referral to social work for home health attendant.  The provider note indicated the patient would be having frequent chemotherapy infusions, follow up with pain management, and provider who treats her insomnia.  At issue is the medical necessity of Personal Care Services, 5 hours a day, 5 days a week for a total of 25 hours per week.

The requested services are medically necessary.

The patient's medical provider and social worker requested an increase in PCA hours based on patient's medical diagnoses and functional limitations. The patient has metastatic breast cancer with active/ongoing therapy with the need for frequent infusions of chemotherapy and follow up with medical providers.  The patient uses a wheelchair outside of the home and requires assistance with transportation, locomotion, and walking when out of the home.  The requested increase in PCA hours is not solely for supervision, safety, and companionship but to assist the patient with safe completion of activities of daily living (ADL) / Instrumental activities of daily living (IADL) tasks.  The assessment tool  underestimated the patient's assistance needs and time needed to complete ADLs/IADLs with progression of metastatic breast cancer, active therapy for metastatic breast cancer, and the time needed to attend multiple treatments for metastatic breast cancer.  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.