Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic breast cancer, leptomeningeal melanoma (malignant brain cancer), whole brain radiation. 
Treatment: Home health care (HHC) / personal care - level 2 personal care services, per 15 minutes increase to 40 hours per week. 

The insurer denied coverage for home care / personal care - level 2 personal care services, per 15 minutes increase to 40 hours per week. 

The denial is overturned. 

The patient has a past medical history significant for metastatic breast cancer, leptomeningeal melanoma (malignant brain cancer), whole brain radiation with resultant memory deficits. She continues on daily oral chemotherapy and intravenous (IV) infusions every three weeks. She also has urinary incontinence, generalized weakness requiring wheelchair for mobility, frequent urinary tract infections, she has seizure disorder, iron deficiency anemia, and chronic pain. Her husband is returning to work, and she needs 24/7 supervision and assistance due to her weakness, incontinence, memory and balance impairments. She is at high risk for falls and infections (e.g., if urine or stool is not cleared in a timely manner) if unattended. 

The member's denial notice was primarily based upon the Uniform Assessment System (UAS) and did not adequately capture the member's functional status and medical conditions. The denial stated that the member had "no loss of motor function... 'your memory is ok' and 'there is no report of bowel and bladder incontinence." All three of which are not true. Based on primary care physician (PCP) clinical notes, it is clear that the member is wheelchair dependent, has impaired balance and generalized weakness, urinary incontinence with recent urinary tract infection, and has memory impairment from her previous whole-brain radiation. In addition, her functional status is expected to continue to decline as her incurable cancers progress. 

The reviewer has been asked to determine if her request of increasing her home care hours from 29 to 40 hours per week is medically necessary. 

The health care plan did not take into account clinical information provided by the member's healthcare providers that clearly documented her functional impairments qualifying her for 24/7 supervision, including 40 hours of professional assistance per week. Her request for 40 hours of home health services per week was unreasonably denied and is medically necessary. 

The member has brain and breast cancer, with seizure disorder, cognitive impairments, generalized weakness, incontinence, and inability to care for herself. She is at high risk for falls and urinary tract infections. Her husband is able to care for her when he is off work - but she will need personal care HHC for 8 hours per day or 40 hours per week. 

"When friends and family are unavailable or unable to care for homebound loved ones, primary care often deploys Home and Community Based Services, including home health aides. For these homebound older adults, home health aides are essential to help preserve an independent life at home and avoid nursing home care" (D'Cruz, L., et al. 2022). 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 40 hours per week is substantiated.