Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic Breast Cancer.
Treatment: Increase to 12 hours per day, 7 days per week- total 84 hours per week personal care services level 2.
The insurer denied an increase to 12 hours per day, 7 days per week- total 84 hours per week personal care services level 2.
The determination is overturned.

The patient has a past medical history of dementia, urinary incontinence, metastatic breast cancer, coronary artery disease (CAD), left carotid stenosis, poor memory, diabetes mellitus (DM) Type 2, depression, dizziness, congestive heart failure, gastroesophageal reflux disease (GERD), constipation, Parkinson's disease with tremor, hypertension, hyperlipidemia, pancreatic insufficiency, iron deficiency, osteoporosis and spinal stenosis who had been assigned personal care assistant (PCA) services 9 hours/day, 7 days/week, to total 63 hours/week based on an assessment tool performed assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, stairs, shopping, transportation, bathing, dressing lower body, and toilet use while extensive assistance with tasks of managing finances, managing medication, phone use, personal hygiene, dressing upper body, walking, locomotion, and transfer toilet. The patient was assessed at limited assistance with the tasks of bed mobility and eating.
Notes from the assessment stated the patient had spasticity and all over body weakness, tremor, and loss of control over walking, postural instability, and difficulty transferring. In addition, the assessment notes stated the patient mostly stayed in bed until the aide came and had no informal helper. The patient's primary care physician (or provider) (PCP) provided a letter stating that the patient was recently diagnosed with metastatic breast cancer that had traveled to her spine, liver, and lymph nodes. The PCP's letter further stated that the patient has been more worried about being alone and it would be beneficial for the patient to receive an increase in home care hours in order to ensure her safety and health based on her current conditions.
The patient underwent a telephonic assessment tool assessing the patient at total assistance with meal preparation, ordinary housework, and shopping while maximum assistance with tasks of stairs, transportation, bathing, dressing lower body and toilet use. With the tasks of managing medication, phone use, personal hygiene, dressing upper body, walking, locomotion, and transfer toilet the patient was assessed at extensive assistance while limited assistance with the tasks of managing finances, bed mobility and eating. Notes from the telephonic assessment stated the patient had no informal helper and did infrequently have bowel incontinence. In addition, notes from the assessment stated the patient could ambulate short distances using a walker and 1 person assistance, stayed in bed until her PCA came and the PCA assisted her to bed before leaving. The insurer sent an initial adverse determination denial notice denying the request to increase PCA services to 12 hours a day, 7 days/week, to total 84 hours/week stating there was no significant change in the patient's functional status. The insurer sent a final adverse determination denial notice continuing to deny request to increase PCA services stating the request was not medically necessary and there had been no change in the patient's medical conditions including her treatment for breast cancer. The denial further stated New York State law does not allow health plans to provide aide services for safety and/or supervision and the patient may be eligible for social daycare to meet those needs. The patient's PCP provided another letter stating it would be beneficial for the patient to receive an increase in home care hours in order to ensure her safety and health based on her current conditions.
At issue is the medical necessity of an increase to 12 hours per day, 7 days per week- total 84 hours per week personal care services level 2.
The services are medically necessary.
The patient is documented to have chronic progressive medical conditions of spinal stenosis, osteoporosis, Parkinson's disease, and metastatic breast cancer. The patient has no informal helper as documented on both assessment tools. The patient stays in bed until her aide arrives and is helped back to bed when her aide leaves. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The patient had an increase in assistance needs with tasks of meal preparation, ordinary housework, and shopping. The patient's previous assessment showed she required maximum assistance with toilet use and extensive assistance with transfer toilet. Given the patient's unpredictable and unscheduled care needs, she should have had more PCA hours based on her assessment. The requested increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of instrumental activities of daily living (IADLs). Given that the patient does not have informal help, the patient should not have to stay in bed later in the day just because she does not have assistance until that time. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.