Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tier 4 Autism

Treatment: Personal Care Assistance

The insurer denied the personal care assistance. The denial was reversed

This is a young male patient with a history of autism, developmental delay, macrocephaly, and arachnoid cyst of the brain. The patient was noted to be nonverbal and communicated by making sounds. He is unable to perform activities of daily living (ADLs) due to his mental, behavioral and developmental disorders. The patient needed maximal assistance for telephone use, climbing stairs, transportation, escort to healthcare appointments and school tasks. He had poor safety awareness, unaware of social cues, and was rigid with daily routines. It was reported that the patient has sensory issues causing him to be unable to tolerate clothes with tags; this also creates difficulty for the patient with brushing his teeth. The patient was noted to have dysphagia and he had trialed feeding therapy but was unsuccessful due to gagging and spitting out of food.  The patient received physical therapy three times weekly and occupational therapy three times weekly for core strengthening, postural training, balance and coordination, age appropriate gross motor skills. The patient attended school with applied behavioral analysis (ABA). A request was made for personal care assistance.

The patient received physical therapy three times weekly and occupational therapy three times weekly for core strengthening, postural training, balance and coordination, age appropriate gross motor skills. The patient used a supramelleolar orthotic to improve his gait. He had unsteady gait and needed assistance during ambulation. He also needed therapy for handwriting, and had weakness with visual sequential motor skills. The patient needed to work on improving his grasp, fine motor and coordination. The patient was also noted to have deficits in expressive speech requiring the use of augmentative communication device. The patient had chewing deficits and oral dysphagia, and was recommended to be monitored for the patient's nutritional intake. As per psychological evaluation the patient was at risk for elevations in the emotionally reactive axons, depression, pervasive developmental problems. The patient was noted to be afraid of new people and situation. As per assessment by the Behavioral Pediatrician the patient was noted to be easily distracted, disorganized in speech, and the patient's mental function varied over the course of the day. The patient was noted to have irritability, hyperactivity, and memory problems.

The patient needed cueing in activities of daily living (ADLs) due to his mental, behavioral and developmental disorders. The patient attended school with applied behavioral analysis (ABA). The patient could not be left alone due to poor safety awareness. The patient had behavioral outbursts when demands were placed on him. The patient was noted to be nonverbal and communicated by making sounds. The patient's mother expressed concern that there was regression in this patient's developmental milestones and functional abilities. 

The health care plan did not act reasonably with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the requested Personal Care Assistance is reversed.  The medical necessity is substantiated.