Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic Cancer, Left Humeral Fracture. 
Treatment: Home Care / Personal Care HHC (home healthcare) -Level 2 Personal Care Services, per 15 minutes increase to 24 Hour(s) per Day (Live In). 
The insurer denied coverage for Home Care / Personal Care HHC -Level 2 Personal Care Services, per 15 minutes increase to 24 Hour(s) per Day (Live In). 
The denial is overturned. 

This is a patient who fell, fractured their left humerus and subsequently was diagnosed with metastatic cancer (unknown primary site). The patient is currently residing in a skilled nursing facility with the plan to return to their private residence (alone) with personal care home care services. The patient is approved for home care / personal care home health care (HHC) - level 2 personal care services, per 15 minutes 60 hours/week. The request is for  home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in) that was denied by the insurer, leading to an external review. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." The patient is reportedly total dependent for performing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient is also reportedly total dependent for bathing and lower body dressing. Maximal assistance is reportedly needed for personal hygiene, upper body dressing and toilet use. Extensive assistance is reportedly needed for eating and bed mobility. The patient is essentially "bed-bound" with no functional ability for locomotion, transfers or ambulation. The patient is frequently incontinent of bladder and bowel. The patient's fall and left humerus fracture led to the metastatic cancer diagnosis. 

The letters from the patient's treating physicians documenting the patient's clinical condition of terminal metastatic cancer and need for home care services were reviewed.  This physician would agree; the patient's clinical condition, functional deficits and guarded prognosis are at a level and unpredictable as to require the requested PCA (level 2) services 7 days per week, 24 hours per day (live-in). Based on the clinical records, a live-in PCA is also likely capable of consistently obtaining approximately 5 hours of uninterrupted sleep over the course of a 24-hour shift.  Based on the documents reviewed, the patient's functional needs would be appropriately provided and maintained by the requested home care / personal care HHC - level 2 personal care services, per 15 minutes PCA (live-in). 

The healthcare plan did not act reasonably, with sound medical judgment and in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Home Care / Personal Care HHC -Level 2 Personal Care Services, per 15 minutes increase to 24 Hour(s) per Day (Live In) services is substantiated.