Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Small cell lung cancer
Treatment: Consumer Directed Personal Assistance (CDPA) Basic: 80 hours a week.
The insurer denied Consumer Directed Personal Assistance (CDPA) Basic: 80 hours a week.
The determination is overturned.

This is a female patient with a medical history notable for small cell lung cancer. The patient is approved for 45 hours per week of consumer directed personal assistance. The patient and her care team requested an increase to 80 hours per week, and this request was denied by the health plan.
The patient's office visit notes from her treating oncologist were provided for review. The patient was hospitalized with left sided paresthesias when a magnetic resonance imaging (MRI) scan revealed right sided brain metastases from her lung cancer. She was started on whole brain radiotherapy. She was diagnosed with a deep vein thrombosis (DVT). Two new brain metastases were discovered. Two new foci of disease were discovered in her liver. The patient was hospitalized for a biopsy and had the complication of hemothorax formation. She notes fatigue and diarrhea from treatment.
A Uniform Assessment System (UAS) was completed and was available for review. The patient's cognition was intact. For her Instrumental activities of daily living (IADLs), she required total dependence for housework. She required maximal assistance for meal preparation and transportation. She requires limited or extensive assistance for all others. For her activities of daily living (ADL), she required extensive assistance for bathing, toilet transfer, and dressing lower body. She required limited assistance for hygiene and toilet use. She was independent for all others. She was occasionally incontinent of urine and infrequently incontinent of stool. A task tool associated with the UAS recommended 32.28 hours per week to address her personal care needs.
The patient was admitted to the hospital after a routine liver biopsy resulted in a hemothorax. She was stabilized and subsequently discharged. Regarding her functional status, the discharge summary made several notations. The patient requires an assistive device and the assistance of another person for safe ambulation. She is confined to a bed or a chair with minimal exertion. She has limited endurance and cognitive impairment. She is home bound and unable to negotiate stairs to her apartment. She had an open draining wound. She had multiple functional limitations due to pain. She has an unsteady gait. At issue is the medical necessity of Consumer Directed Personal Assistance (CDPA) Basic: 80 hours a week.

The requested health service of Consumer Directed Personal Assistance (CDPA) Basic: 80 hours a week is medically necessary for this patient.
The patient's most recent UAS was completed. At that time, she did require assistance with toileting. The notes indicate that her clinical status has worsened since then. This is to be expected as she has lung cancer that has metastasized to the brain and the liver. Her metastases are increasing in number despite treatment. At the time of her recent discharge from hospitalization, she required hands-on assistance with ambulation, transfers, and toileting. Her more updated information from her care team indicates that her care needs will be continuous and unscheduled throughout the day. Therefore, the requested increase to 80 hours per week of personal assistance is medically necessary and reasonable for the patient.