Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stage 4 Lung Cancer

Treatment: Home Care / Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 84 Hour(s) per Week

The insurer denied coverage for Home Care / Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 84 Hour(s) per Week.

The denial is overturned.

This is a patient with stage 4 lung cancer. The patient is approved by the insurer for personal care assistance (PCA) services 56 hours/week. A denial of coverage for Home Care/Personal Care Home Health Care (HHC) - Level 2, Personal Care Services, per 15 minutes, increase to 84 hours per week has resulted in an external review.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as minimally impaired. The patient is reportedly total dependent for performing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, lower body dressing, and toilet use. Extensive assistance is reportedly needed for personal hygiene, upper body dressing, locomotion, toilet transfer and ambulation. The patient is reportedly at the supervision level or independent with eating and bed mobility. The patient is reportedly frequently incontinent of bladder and continent of bowel. 

The patient's activities of daily living (ADL) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. The patient's cognitive and functional ability has declined when compared to the UAS reports. A letter from the patient's treating physician, describing the patient's clinical condition and need for additional PCA services was reviewed. The patient's physician also submitted a treatment note. The patient is described as "Alert and oriented x3 (person, place and time), cranial nerves intact, sensory and motor normal." There was no specific functional assessment. However, a more recent treatment note from the patient's provider indicates the patient's "condition is deteriorating, he is becoming weaker and experiencing problems ambulating." Also included is an ADL/Night Time Log describing the PCA services provided at night and early morning. After reviewing the enclosed documents which demonstrate evidence of continuing functional decline, this physician would agree the patient's clinical condition and functional deficits have declined and support the medical necessity of the requested home Care/Personal Care HHC - Level 2, Personal Care Services, per 15 minutes, increase to 84 hours/week. 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, Home Care/Personal Care HHC - Level 2, Personal Care Services, per 15 minutes, increase to 84 hours/week is medically necessary. 

Based on the above, the insurer's denial must be reversed. 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 84 Hour(s) per Week services is substantiated.