Appeal type: Medical necessity
Decision: Overturned

Cancer
Home Health Aide

Diagnosis: Cancer-Metastatic Endometrial.
Treatment: Personal Care Services.
The insurer denied Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: Increase to 24 Hours per Day (Live In). 
The health plan's determination is overturned. 

The patient is a female with metastatic endometrial cancer, protein malnutrition, diabetes mellitus, urinary incontinence, hypertension and glaucoma who had PCA (personal care assistant) services. There was a request to increase PCA hours and the patient underwent telephonic assessment that assessed the patient at total assistance with tasks of ordinary housework and maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with tasks of stairs, transportation, and dressing lower body while limited assistance with tasks of managing finances, managing medication, bathing, dressing upper body, walking, locomotion, transfer toilet and toilet use. With the tasks of personal hygiene, bed mobility, and eating the patient was assessed as independent. The patient was admitted to hospice with hospice notes indicated the patient was using rollator walker. The patient's hospice physician provided a letter requesting a split shift PCA services to address her nighttime needs. The letter stated the patient had continued to decline significantly, had nausea/vomiting, constipation and diarrhea, had multiple falls, was incontinent of bowel and bladder, and was still self directing. In addition, the hospice physician's letter stated the patient's nightly needs had become unpredictable and the patient did not have the strength to use bedside commode without assistance.

Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: Increase to 24 Hours per Day (Live In) is medically necessary for this patient.
The patient has documented progressive medical condition of metastatic endometrial cancer. There is documentation of the patient's worsening functional status. Specifically, there is documentation that the patient is bedbound, has bowel and bladder incontinence, and is total assistance with all activities of daily living (ADL)/ Instrumental activities of daily living (IADL) which is a change in assistance needs since the recent assessment tool. The increase in PCA services is not solely for safety and supervision, as the plan argues, but to assist the patient with safe completion of ADLs/IADLs. The patient has unscheduled and unpredictable care needs. The patient's care needs cannot be met solely with medical supplies and adaptive equipment. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: Increase to 24 Hours per Day (Live In) 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.