Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Home Health Care.
The insurer denied Personal Care Worker (PCW) service- 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person. 
The denial is overturned. 

The patient is a female with a past medical history of gastrointestinal stromal tumor (GIST) of small bowel with metastases to the brain, hypertension, hepatitis C, and osteoarthritis who had been assigned personal care aide (PCA) services following assessment  which assessed the patient at total assistance with tasks of meal preparation, ordinary housework, and shopping while maximum assistance with tasks of transportation, bathing and dressing lower body. With tasks of managing finances, managing medication, phone use, stairs, equipment management, personal hygiene, dressing upper body, and transfer to the toilet the patient was assessed at extensive assistance while limited assistance with tasks of walking, locomotion, toilet use, bed mobility, and eating. The patient had a fall and was admitted to the hospital with evaluation leading to the diagnosis of a 6.1-centimeter (cm) brain mass with decision not to have operative intervention during that hospital admission. The patient was seen by neurosurgery with a plan for palliative treatment of large, presumed metastatic brain mass. 
The insurer sent final adverse determination denial notice denying the request to increase PCA services stating the patient's needs could be scheduled and the patient could be left alone safely. The denial stated the plan was not required to include safety monitoring as a separate task as part of the total personal care service hours authorized.
At issue is the medical necessity of Personal Care Worker (PCW) service- 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person.

The health plan's determination is overturned in whole.

The requested health service/treatment of Personal Care Worker (PCW) service- 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person is medically necessary for this patient.
There is documentation of worsening functional status based on the patient's new diagnosis of brain tumor. The patient's condition will have natural progression with worsening functional status as she has elected for no further treatment and was placed on hospice care. The patient's PCP documented overnight care needs of bathroom assistance 1-2 times per night which would not allow a PCA 5 hours of uninterrupted sleep. The patient also requires assistance with walking, locomotion, transfer to the toilet, toilet use, bed mobility, and eating. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies as the insurer indicated. The patient's care needs are not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL)s and Instrumental activities of daily living (IADL)s. 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 24 hours/day 7 days/week, to total 168 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.
Therefore, the requested health service/treatment of Personal Care Worker (PCW) service- 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person is medically necessary for this patient.