Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Global developmental delay.
Treatment: Personal Care Assistance, Pre-service.
The insurer denied the Personal Care Assistance, Pre-service.
The denial is overturned.

The patient is a female child with multiple food allergies (milk, eggs, yogurt, sesame seeds, pretzels), global developmental delay, and hypotonia of unclear etiology. Her presentation is similar to an older female sibling with global and cognitive delay. Both children are undergoing genetic assessment to determine etiology. This child has delays in all areas. She is delayed in speech, unable to communicate wants or needs, unable to point to objects of interest, inconsistently following commands. She is able to respond to her name and responds to sounds appropriately. She is able to crawl but cannot walk, with poor balance and low muscle tone. She is unable to perform age-appropriate activities of daily living.

The patient lives with her parents and multiple siblings. As of the documentation acquisition, the mother was pregnant. The mother is the primary caregiver, managing all of the children and the home. The father works outside of the home Monday-Friday 0800-1900 with unknown commute time. The child receives early intervention services at home Monday-Thursday for thirty minutes before school. She attends school 0930-1500, where she receives physical therapy twice weekly, speech therapy twice weekly, occupational therapy four times weekly, and special education twice weekly. About half of the therapy sessions are conducted in the home and half are conducted in school.

The patient's personal care assistance needs include continuous monitoring for safety and assistance with all activities of daily living above and beyond what would be required for a child this age, including toileting, dressing, feeding, and mobility.

Yes, personal care assistance is medically necessary and appropriate for this child.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
According to the American Academy of Pediatrics Guidelines for Home Care of Infants, Children, and Adolescents With Chronic Disease, "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens." (1) Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities." (1)

This child is globally developmentally delayed due to an as-yet-undetermined neurologic condition (an older sister's condition has similar features) and is unable to function in an age-appropriate manner. While she has all of the typical needs of a toddler her age, she has retained all of the needs of an older infant/younger toddler as well. She is unable to communicate her wants and needs, she is unable to point to things that she wants, she is unable to walk and is limited to crawling for mobility, she is able to chew but does so slowly and must be closely monitored for choking, and she has numerous food allergies and must be closely monitored so as not to be accidentally exposed (her ability to follow directions is limited beyond what would be expected for a child her age). She remains fully dependent upon caregivers for all activities of daily living and must be constantly monitored for safety. While it is not unreasonable to expect primary caregivers to participate in meeting their children's needs, this mother with multiple young children and the only adult available to provide care while the father is working eleven or more hours daily outside of the house, is not able to maintain the level of care that this child requires for safety and functional development. Personal care assistance services are medically necessary and appropriate in this situation.