Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Attention deficit hyperactivity disorder (ADHD)
Treatment: Personal care assistance (PCA) services
The insurer denied coverage for personal care assistance (PCA) services.
The denial is upheld.

This teenage female reportedly had a diagnosis of attention deficit hyperactivity disorder (ADHD)-combined presentation, post-traumatic stress disorder (PTSD), and mild intellectual disability, and had past mood disorder diagnoses of bipolar or depressive disorder.  She reportedly had an intelligence quotient (IQ) of 65. She reportedly had a history of learning disabilities, speech/language impairment, and enuresis. She reportedly was 28 weeks pregnant. She reportedly was in a group home living semi independently with staff to supervise activities of daily living (ADLs). She reported being bullied in the past. It was reported that there was child protective services (CPS) and court involvement in the past. She reportedly witnessed domestic violence by her father to her mother. She reported that she was arrested in the past though wouldn't elaborate and reported that the charges were dropped. She reportedly had poor attendance in school. It was reported that she was not taking psychotropic medications but was in psychotherapy. She reportedly had past gang involvement. It was reported that she admitted to vaping nicotine and using marijuana. It was reported that she took Adderall and Risperidone in the past. She reportedly had a psychiatric evaluation by a pediatrician who recommended a drug screen, possible medication for ADHD, individual therapy, and recommended a home health aide (HHA) to assist her in taking medications and ADLs. They stated that the group home that she was living in was not a skilled nursing facility and was unable to assist her in ADLs. 

The insurer denied the request for personal care assistance (PCA) services as not medically necessary. The insurer indicated that the assessment shows that the patient is able to perform daily activities expected of a child of the patient's age. They stated that the M 11Q (Medical Request for Homecare) reflects chronic or other conditions that do not impact the patient's ability to perform daily activities expected of a child the patient's age. 

There was no specific documented evidence supporting that the patient could not perform ADLs expected of a child her age to the point of requiring PCA services or HHA. She reportedly was living in a group home that could help her with medication dispensing and prompting of ADLs. There was a note in the medical records stating that the patient was living semi independently in a group home with staff able to supervise ADLs. 

There was not sufficient specific evidence to support that she was unable to function in the group home setting to the point of requiring PCA services. As a result, the recommendation is to uphold the previous decision and deny coverage for PCA services as not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for PCA services is not substantiated.