Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast cancer metastatic to the brain.
Treatment: home care/personal care HHC (home health care)-Level 2 Personal Care Services, per 15 minutes (mins) increase to 24 hours (hrs.) per day (split shift).
The insurer denied home care/personal care HHC-Level 2 Personal Care Services, per 15 minutes (mins) increase to 24 hours (hrs.) per day (split shift).
The determination is overturned.

This female patient has a medical history notable for breast cancer metastatic to the brain, complete paraplegia, bed-bound status, bowel and bladder incontinence, and dysphagia. The patient is approved for 48 hours per week of level 2 personal Care services. The patient and her care team requested an increase to 24-hour split-shift care.
A Uniform Assessment System was completed. For her instrumental activities of daily living, the patient requires total dependence or maximal assistance for essentially all. For activities of daily living, the patient requires total dependence on toilet use. She requires maximal assistance for dressing her lower body, bathing, and locomotion. She requires extensive assistance for hygiene, dressing her upper body, and bed mobility. She requires limited assistance for eating. The patient is paralyzed from the waist down due to her metastatic cancer. She is unable to walk or stand. She is incontinent of urine and stool with no control present and wears diapers for incontinence care. 
The patient's oncologist provided a letter of support. The letter states that the patient is paralyzed from the waist down and at great risk for falls and injury. She has a history of urinary tract infections. The physician states that frequent diaper changes are necessary for the patient to prevent urinary tract infections. The physician states that she will require 24-hour continuous split-shift care.
The letter states that the patient is wheelchair-bound and has decreased mobility of her upper extremities as well. She is extremely debilitated in the setting of her metastatic breast cancer. The physician feels that having around-the-clock personal care is imperative to allow for turning and repositioning to alleviate pain and discomfort from her metastatic disease. It is also necessary for incontinence care to prevent a urinary tract infection.
The patient's physiatrist provided a letter of support. The letter states that the patient requires assistance with transfers, mobility, bathing, and toileting. Her family is not able to assist. The physician recommends 24-hour per day split shift care to meet her personal care needs.
Overnight care logs were available for review. The patient requires assistance approximately every 2 hours overnight with turning and repositioning. She also requires frequent diaper changes after episodes of incontinence. There were no significant breaks in personal care needs overnight. At issue is the medical necessity of home care/personal care HHC-Level 2 Personal Care Services, per 15 minutes (mins) increase to 24 hours (hrs.) per day (split shift).

The requested health service of home care/personal care HHC-Level 2 Personal Care Services, per 15 mins increase to 24 hrs. per day (split shift) is medically necessary for this patient.
The patient's personal care needs are pervasive. She is not able to complete any activities of daily living without assistance. She has full incontinence of bowel and bladder and is not able to manage her incontinence care products alone. She requires assistance with turning and repositioning due to painful metastatic disease. Her personal care needs are expected to be continuous and unscheduled throughout the day and night. A live-in personal care aide would not be able to receive sufficient rest. Therefore, 24-hour split shift personal care is medically necessary for the patient. Failure to address her personal care needs could result in skin breakdown, infection, and or injury.