Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal - Other
Home Health Care

The patient is a female with a past medical history of diabetes mellitus type 2, hypertension, hyperlipidemia, osteoarthritis, dementia and osteoporosis who had level 2, personal care assessment services, per 15 minutes 80 hours per week based on an assessment tool. At that time the patient attended adult day care three days a week. The patient was subsequently diagnosed with squamous cell cancer of the esophagus and initiated radiation therapy and chemotherapy.
The patient's primary oncologist requested an increase in personal care aide services to per 15 minutes 24 hours per day (split-shift) as the patient had weakness due to cancer treatment with difficulty in most activities of daily living (ADLs) and required assistance with getting to chemotherapy and daily radiation therapy appointments. The patient was subsequently hospitalized with aspiration pneumonia and pleural effusion and again with recurrent aspiration and had placement of percutaneous endoscopic gastrostomy (PEG) tube. The patient was discharged to home with oxygen therapy and had home health services. The patient was set up with hospital bed, mattress and walker. The patient had assessment tool done showing change in level of assistance from the prior assessment in areas of dressing upper extremity (UE)/lower extremity (LE), transfer toilet, toilet use, eating, housework, finances, managing medication, shopping, equipment management, personal hygiene, stairs. There was no change in bathing which remained at extensive assistance. In addition, there was no change in walking or locomotion which remained at supervision only. The more recent assessment noted there was "no change" in ADL status in the last 90 days. Transportation assistance remained at maximal assistance. The son noted the patient needed help getting in and out of the bath, dressing and brushing hair. The patient required assistance 2-3 times at night with toileting, toilet transfer, equipment management (with percutaneous endoscopic gastrostomy [PEG] and oxygen) and walking/locomotion. An increase in personal care services was denied by the health plan. The provider asked for a plan appeal to increase personal care services to per 15 minutes 24 hours per week in split shift. This was denied by the health plan and is the subject of this review.

The health plan's determination is overturned.

Yes, the requested treatment of home care/personal care HHC - Level 2 Personal Care Services per 15 minutes to 24 hours per day (split shift) is medically necessary for this patient. The patient had an increase in personal care needs on the most recent assessment. In addition, the patient was no longer attending adult day care program at the time the assessment was done. The patient had a new personal care need of equipment management since her last assessment, as she had to navigate the use of oxygen and PEG tube. The patient's walking and locomotion assessment indicated she needed supervision, but the patient's provider and son noted that the patient required at least limited assistance. The patient's nighttime needs changed from previous assessment due to increased weakness from recent chemotherapy treatment and hospitalization in the setting of having new oxygen equipment to maneuver at night. She required extensive assistance with toilet use and toilet transfer in the overnight hours. Her son was not able to help with these unscheduled needs overnight.