This is a patient with a past medical history of hepatocellular carcinoma, cirrhosis, pleural effusion, seizure disorder, bipolar disorder, hepatic encephalopathy, dependence on supplemental oxygen and weakness who had assessment tool for personal care assistant (PCA) services performed and was approved for 18 hour/week. There was an appeal to increase PCA services hours to 30 hours/week which was denied by insurer. The patient was hospitalized with ascites, edema and pleural effusion. The patient was not felt to be candidate for further treatment of hepatocellular carcinoma and due to this and complications from end stage cirrhosis was discharged to home on hospice. The discharge summary from the hospitalization documents the need for increased home services. The patient's oncologist wrote a letter to the health plan noting the need for increased PCA service hours due to patient's weakness, fatigue, difficulty with ambulating (using rolator walker), forgetfulness, need for help with meal preparation and medication reminders. This letter specifically requested and increase in PCA hours to 60 hours/week. The patient's hospice and palliative care provider wrote a letter to insurer noting the patient needed an increase in PCA service hours Monday through Friday, to total 50 hours/week. The health plan denied increase personal care assistance services 6 hours per day, 5 days per week - total of 30 hours per week.

The patient had a significant change in his health status from the previous assessment tool. There was a request for an increase in PCA hours in, but since that time the patient had further decline in his health status following hospitalization. During this hospitalization the patient was deemed appropriate for hospice. According to his oncologist and palliative care physician the patient had increased pain, forgetfulness and fatigue making it difficult for him to ambulate, manage medications, prepare meals, bathing, locomotion, walking and personal hygiene. From the previous assessment tool, the patient was assessed at limited assistance for most of these tasks and based on worsening medical condition and with anticipated deterioration of health (on hospice) assistance will be at least maximum and possibly total.