Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lymphoma 
Treatment: Personal Care Aide (PCA) 12 hours/day, 7 days/week, total 84 hours/week 
The insurer denied the request for PCA 12 hours/day, 7 days/week, total 84 hours/week. 
The health plan's determination is overturned. 

The patient is a female with a medical history notable for lymphoma, incontinence, and gastrostomy tube placement. The patient is approved for 5 hours/day, 7 days/week (35 hours/week) of personal care aide (PCA) services. The patient and her care team requested an increase to 12 hours/day, 7 days/week (84 hours/week), and the request was denied by the health plan. 

The patient's physician provided a letter of support for this appeal. The letter states that the patient has B cell lymphoma, history of rectal cancer with colostomy and gastrostomy tube, fecal incontinence, anemia, diabetes mellitus type 2, hypertension, and an unsteady gait. The patient is homebound and requires care throughout the day. The physician reports that her condition has been worsening over the past year. She needs assistance with personal care tasks including toileting, transfers, repositioning, ambulating with a walker, meal preparation, and bathing. She lives alone and requires help with unscheduled personal care needs throughout the day. Therefore, the physician requests an increase in hours to cover the patient's needs while she is awake.

The patient's child provided a letter of support. The letter states that the patient lives alone. Her child visits occasionally but is not able to provide consistent support. There are no other friends or family members providing informal support to the patient. 

Office visit notes were provided for review. They state that the patient has been functionally declining and needs more help at home. She has urinary incontinence which is worsening with continuous leakage and requires changes. She has incontinence of fecal material as well as a stoma. 

A Uniform Assessment System (UAS) was completed in the beginning of this year and was available for review. The assessment was conducted in-person. The patient was alert and oriented with forgetfulness. Her recall was 2 out of 3 at five minutes and her procedural memory was intact. For her instrumental activities of daily living (IADLs), she requires maximal assistance for meal preparation, housework, and shopping. She requires extensive assistance for medications, stairs, and transportation. For her activities of daily living (ADLs), she requires extensive assistance for bathing, dressing lower body, walking, locomotion, toilet transfers, toilet use, and bed mobility. She requires limited assistance for hygiene and dressing upper body. Her overall self-sufficiency had deteriorated. She is frequently incontinent of urine. She has an ostomy with continuous stool output. Compared to a prior assessment from beginning of last year, she showed a functional decline. 

The patient requires hands-on assistance for all ADLs including ambulation, transfers, toileting, and incontinence care. Her last UAS demonstrated this need in the beginning of this year, and her physician attested that her condition has continued to decline. Her care needs are expected to be continuous and unscheduled throughout the day. This is also reflected in the personal care logs provided by the caregiver. Therefore, the requested increase is medically necessary and reasonable for the patient.
 
The health plan's determination of medical necessity is overturned in whole.