Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism. 
Treatment: Personal Care Assistance. 
The health plan denied Personal Care Assistance. 
The denial is upheld. 

The patient is a male toddler who was reported to have been diagnosed with autism spectrum disorder (F84.0). The request is for in-home personal care assistance services for the patient. The requested service was noted to have been previously denied coverage by the health plan, as the patient was noted to have chronic conditions that does not impact his ability to perform daily activities expected of his age. The denial further indicates that personal care assistance services for safety and supervision alone is not medically necessary unless it is provided as part of assistance with activities of daily living. The patient was noted to be medically stable, and the patient or the patient's caregivers were noted to be able to complete daily tasks for the patient.

An appeal letter provided by the patient's treating therapist states that the patient and his mother have been receiving group attachment-based interventions. The provider indicates that the interventions are a form of parent-child psychotherapy that focuses on building secure and not less attachment between parents and their young children. The provider further states that the patient's mother has three little children, and two of them have been diagnosed with autism spectrum disorder, including the patient. The patient's mother was also reported to have been enrolled in online academic classes. She was reported to have significant challenges to manage the household, including supervising the patient who has special needs. The patient was reported to have frequent dysregulation and impulsivity that requires constant supervision. The provider indicates that tasks for the patient's mother such as laundry, shopping and preparing meals has been stressful.

A comprehensive pediatric assessment was noted to have been performed. The patient was noted to have two siblings who are attending school. One brother was reported to have been diagnosed with autism spectrum disorder. The patient was reported to have some speech delay and difficulties with verbal expression. However, the patient's vocabulary was noted to have been improving with therapy. The patient was reported to have been attending early intervention services. The assessment indicates that the patient's mother has difficulties with meal preparation, housework, laundry, managing medications, shopping, medical appointments, and performing activities of daily living for the patient due to the patient's symptoms.

Clinical documentation provided does not indicate that the patient had any clinical condition that would impact his ability to perform age-appropriate activities of daily living. It is notable that the patient is a male toddler who would normally need assistance with most activities of daily living even in the absence of any significant medical condition. There was no indication that the patient's diagnosis of autism spectrum disorder has resulted in any significant functional impairments in the child that requires in-home personal care assistance services. There was no indication that the patient had any significant medical conditions that required frequent care or interventions. The patient's caregivers are able to complete the essential daily tasks for the patient.