Diagnosis: Breast cancer, incontinence
Treatment: Personal Care Services (PCS) - 24 hours/day, 7 days/week (split shift)
The insurer denied PCS - 24 hours/day, 7 days/week (split shift).
The health plan's determination is overturned.

The patient is a female with metastatic triple negative breast cancer, urinary incontinence, bowel incontinence, severe arthritis of bilateral shoulders, recurrent urinary tract infection (UTI), Parkinson's, and obesity who had been hospitalized with hematuria versus vaginal bleeding. The patient was diagnosed with UTI/sepsis, right internal iliac vein thrombosis, and new pathologic fracture of the sacrum. The patient was treated with antibiotics for UTI/sepsis and anticoagulation for deep vein thrombosis (DVT) but had further hematuria and had an inferior vena cava (IVC) filter placed. During the discharge planning process, the patient underwent a telephonic assessment for PCA (personal care aide) services.

Personal Care Services (PCS) - 24 hours/day, 7 days/week (split shift) are medically necessary for this patient.

There is documentation from the patient's medical providers of medical necessity of increased PCA services. There is documentation of the patient's medical records of worsening functional status due to recent hospitalization, anemia, urinary tract infection (UTI), further progression of metastatic breast cancer, and worsening of chest wound. There is specific documentation by the patient's medical provider of the need for incontinence care and turning and repositioning every 2 hours which would not allow a PCA 5 hours of uninterrupted sleep. The patient requires at least maximum assistance with locomotion, transfer toilet, and toilet use all of which are 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 requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The plan incorrectly utilized a tasking tool to calculate PCA services despite the patient having 24-hour care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies as the plan suggested. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCS 24 hours/day, 7 days/week, split-shift are medically necessary for this patient. PCS 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.