Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Global developmental delay
Treatment: Consumer Directed Personal Assistance, Pre-service

The insurer denied the Consumer Directed Personal Assistance, Pre-service.
The denial is upheld.

The patient is a male diagnosed with autism spectrum disorder (ASD), unspecified developmental delay, chronic constipation, and gastroesophageal reflux disease (GERD). No clinical records were provided to substantiate any of these diagnoses. The only documents are letters of medical necessity and an evaluation for personal care services (PCS). There is no documentation regarding the number of hours per week or what the goals are for PCS (personal care services), such as what this service is targeting.

No. The proposed treatment is not medically necessary.

Long-term personal care is a range of services and supports to help meet the personal care needs of incapacitated individuals [Pratt, Callen]. Most long-term care is not medical care, but rather assistance with the basic personal tasks of everyday life, sometimes called activities of daily living (ADLs).

Personal care services (PCS) are medically necessary if they meet the following criteria:
1) The patient is impaired in at least two ADLs (activities of daily living) as determined by standardized testing (e.g., Vineland Adaptive Behavior Scales, Third Edition (Vineland-3), Adaptive Behavior Assessment System, Third Edition (ABAS-3), or equivalent tool) with a standard score < (less than) 70 based on input parents and teachers [Not met. No clinical records were provided to substantiate this.]
a)	Bathing
b)	Dressing
c)	Using the toilet
d)	Transferring (to or from bed or chair)
e)	Caring for incontinence
f)	Eating

2) The services relate to physical requirements, when physical limitations are due to illness, injury, developmental delay, or developmental disability requiring assistance with activities of daily living (ADLs) such as eating, bathing, dressing, personal  hygiene, and bladder or bowel requirements. [Not met. No clinical records were provided to substantiate this.]
3)	Without these services, the patient would require intermediate care facility (ICF) or equivalent level of care (e.g., day resident program) [Not met. This is not documented. This patient is not at risk for institutionalization.]
4) The services enable the recipient to be treated on an outpatient basis rather than an inpatient basis to the extent that services on an outpatient basis are projected to be more cost effective than services provided on an inpatient basis [Not met.  The patient does not require inpatient services.]
5) Parent, guardian, or caretakers are physically unable to provide personal care services [Not met. This is not documented.]
6) The services are not to be provided to meet childcare needs or as a substitute for the parent in the parent's absence [Not met.  This appears to be a substitute for the parent.]
7) The services are provided by a qualified individual who is not part of the member's family or household [Met]
8) The services cannot be met by other resources such as respite care or private duty nursing [Not met.  Respite care can achieve the same goals.]
9) Other family members are not available to perform these duties [Not met. This is not documented.]
10) Requested services do not function as a substitute for routine adult or child daycare [Not met. This is not documented.]
11) Requested services do not function as respite care for parents or caregivers [Not met. This is not documented.]

The clinical records submitted for review fail to document the patient meeting all above criteria. Thus, the request for PCS (personal care services) is not medically necessary, appropriate, or standard of care.

Yes. The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

No clinical records were provided to substantiate any of the patient's diagnoses. The following records were not provided for review in this case:

Most recent diagnostic evaluation for ASD (autism spectrum disorder) by a qualified diagnostician (e.g., clinical child psychologist, board-certified child psychiatrist, board-certified child neurologist, board-certified developmental-behavioral pediatrician, board-certified neurodevelopmental pediatrician) administering an appropriate module of the ADOS-2  (Autism Diagnostic Observation Schedule) accompanied by review of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) diagnostic criteria.

Most recent standardized testing of intelligence and language.

Most recent standardized testing of adaptive skills using the Vineland-3, ABAS (Adaptive Behavior Assessment System) -3 with input from parents and teacher.