Diagnosis: Ovarian cancer with metastasis to the liver and bilateral pleural effusion.
Treatment: PCA (patient care assistant) level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split-shift) for a total of 168 hours per week.
The insurer denied coverage for PCA (patient care assistant) level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split-shift) for a total of 168 hours per week.
The denial is overturned.

The patient is an elderly female requesting home care services. She has a history of ovarian cancer with metastasis to the liver and bilateral pleural effusion. The doctor writes that the patient has had rapid deterioration with functional and nutritional decline. The patient is bedbound, totally dependent on others for all activities of daily living (ADL's), requires repositioning in bed every 2 hours to prevent pressure ulcers, and needs to be spoon-fed to eat. The patient is bedbound, totally dependent on others for all ADL's (activities of daily living) and requires repositioning in bed every two hours to prevent pressure ulcers, and needs to be spoon-fed to eat. The requested services, PCA (patient care assistant) level 2: (12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split-shift) for a total of 168 hours per week) are considered medically necessary for this patient.

Landers, et al., (2016), "America is experiencing a dramatic shift in demographics, and in 2019, people older at geriatric age will outnumber those younger than five. As Americans age and live longer, increasing numbers of them will live with multiple chronic conditions, such as diabetes or dementia, and functional impairments, such as difficulty with the basics of life like mobility and managing one's household. One of the greatest healthcare challenges facing our country is ensuring that older Americans with serious chronic illnesses and other maladies of aging can remain as independent as possible. Our success with this challenge will help ensure that Americans age with dignity in a manner that meets their expectations, preferences, and care needs."

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 PCA (patient care assistant) Level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split-shift) for a total of 168 hours per week services is substantiated.