Colon Cancer
Home Health Care

The patient is with metastatic colon cancer. The patient's past medical history is significant for colon cancer, Alzheimer's dementia, depression, anxiety, diabetes, coronary artery disease, peripheral artery disease, hypertension, insomnia and degenerative joint disease.

The patient's provider requests personal care service assistance, 7 days a week ×12 hours per day (split shift) for a total of 168 hours per week.
The health plan determination is upheld in whole.

No, the requested health service is not medically necessary for this patient. Additional patient care service hours are not medically necessary. This patient with metastatic colon cancer. The past medical history is significant for colon cancer, Alzheimer's dementia, depression, anxiety, diabetes, coronary artery disease, peripheral artery disease, hypertension, insomnia and degenerative joint disease. The patient is approved for 24 hours per day live-in ×2 days per week and 12 hours per day ×5 days for a week for a total of 60 hours a week. Noting the following, most of the patient's ability to perform physical function were maximal assistance and did not change since the previous evaluation. Specifically, the Uniform Assessment System (UAS) stated that it did not support nighttime hours.

On the reassessment, according to the nurse, it was noted that the patient had no recent falls, is able to use incontinence supplies with assistance, patient is able to change position in bed with assistance, and his family pre-pours medication that is administered at night. Safety monitoring and supervision as a stand-alone task is not medically necessary.

The patient has significant needs including most Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). These needs can be met according to the documentation provided in the allotted time. Additional services, specifically services in the nocturnal hours, are not noted to be medically necessary.