Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic lung cancer and cancer related pain. 

Treatment: Increase in personal care services home attendant Level II: 12 hours per day times 7 days per week for a total of 84 hours per week. 

The insurer denied coverage for an increase in personal care services home attendant Level II: 12 hours per day times 7 days per week for a total of 84 hours per week. 

The denial is overturned. 

This is a male patient with a past medical history of metastatic lung cancer, hypertension, insomnia and cancer related pain.  The patient is receiving radiation therapy.  The patient is experiencing side-effects from the radiation therapy, such as weakness, nausea and vomiting.  He lives with his wife in an apartment building with elevator access. The patient uses a walker or wheelchair for mobility.  Due to the patient's pain and side effects of radiation therapy, the patient needs maximal assistance with his instrumental activities of daily living, and he needs total assistance with his activities of daily living.  A Uniform Assessment System (UAS) - New York report was done.  The patient needs extensive assistance with managing medications, phone use and toilet use.  The patient needs maximum assistance with managing finances, bathing, personal hygiene, dressing his upper and lower body, walking, locomotion and toilet transfer.  The patient needs limited assistance with bed mobility and eating. No unscheduled needs are noted.  The patient is incontinent of bladder.  An increase in personal care services home attendant Level II: 12 hours per day times 7 days per week for a total of 84 hours per week is being requested.  

As per the New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016 
(a) Definitions and scope of services. 
(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse. 

The basis for the insurer's denial is lack of evidence of deterioration producing need for 84 hours/week instead of 50 for this patient.  The UAS report indicates bladder incontinence and severe limitation in transfers, ambulation, and mobility except in bed, toileting and cleaning self.  The patient's medical doctor (MD) documents both the extent of impairment as well as recent change in this patient's needs.  The patient's MD notes that the patient has been declining with global deterioration in cognitive and functional status. The patient has incontinence of both bladder and bowel.  

Based on the review of the medical record and literature, the requested increase in personal care services home attendant is considered medically necessary for this patient. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.  

The carrier's denial of coverage for the requested increase in personal care services home attendant Level II: 12 hours per day times 7 days per week for a total of 84 hours per week should be overturned.  The medical necessity is substantiated.