Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism

Treatment: Personal assistance services (PCS)

The insurer denied coverage for personal assistance services (PCS).

The denial is overturned. 

This is a male child with autism, pica, intellectual/developmental disability, dyslexia, and disorder of psychological development.  His cognitive skills are moderately impaired. He has memory problems and is easily distracted; he also has disorganized speech.  He sometimes understands and responds to simple direct commands.  He has extreme changes in mood, exhibits decreased social interaction and withdraws from social activity. The patient's mother claims that the patient is home from school full time.  He receives physical therapy three times weekly, occupational therapy three times weekly and speech therapy three times weekly via Telehealth.  He has pica and needs to be monitored consistently. He is a danger to himself if he is not watched. The patient's mother states that since the COVID-19 pandemic, the patient has regressed and his behavior has gotten worse. He refuses to leave the house and refuses to wear a mask. The patient gets frustrated and upset when his routine is disturbed.  

Adverse childhood experiences (ACE) are traumatic experiences that occur during childhood. ACEs are a serious public health concern and can have long term implications for health and wellbeing. ACEs contribute to poor health outcome, and the pandemic's health and economic impacts exacerbate the risk of ACEs. The article published by Sanders entitled "Is COVID-19 an adverse childhood experience (ACE): implications for screening for primary care" claims that the response to the COVID 19 pandemic may be amplifying some ACEs. There are several ways in which ACEs may be exacerbated by the social isolation, job loss, school closures, and other stressors unleashed by the pandemic. First, the pandemic may have increased intra-familial adversity, by exposing children to increased parental anxieties, especially those associated with job loss, food insecurity and housing insecurity. Second, by amplifying toxic stress, increased family adversity may impair child brain development, particularly during the early years. Third, the pandemic's indirect social and economic impact on family stress may linger for months or years. Taken together, the indirect effects of the pandemic response could exacerbate each of the common ACEs in children's lives.

The patient is totally dependent for bathing and hygiene, requires maximum assistance for dressing extensive assistance for technology, toilet use and eating, limited assistance for toilet transfers and supervision/set up assistance for locomotion, stairs and walking. He has some medical issues including an eating disorder. His pica needs to be monitored due to safety risks of choking and aspiration pneumonia. Due to his regression and worsening behavior as well as increased time at home due to the pandemic crisis, his current personal assistance services (PCS) hours (17 hours per week) are not enough for bathing, dressing, toileting and housekeeping related services.  Therefore the medical necessity of 25 total hours of PCS is medically justified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for 25 total hours per week of PCS is overturned. The medical necessity is substantiated.