Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism, bipolar disorder, learning disabilities, pes planus
Treatment: Consumer directed personal care assistance 21 hours per week
The consumer directed personal care assistance 21 hours per week is medically necessary.

The patient is a teenage male with autism, anxiety, bipolar disorder, pica, oppositional defiant disorder, disruptive mood dysregulation disorder, learning disabilities, and pes planus. He receives multiple medications to manage his psychiatric/psychological/behavioral problems: clonidine, mirtazapine, Prozac, and sertraline. He previously was also treated with lithium, atomoxetine, and Trileptal. He has been hospitalized multiple times for his psychiatric issues. He is cognitively moderately impaired, impulsive, easily distracted, irritable and angry, lacking safety awareness. He is socially inappropriate and disruptive, both physically and verbally abusive at times, and has shown destructive behavior toward animals and property. 

The patient lives with his parents and four other children with special needs. His father works one full-time job and one part-time job outside of the home. His mother manages the home and cares for all of the special needs children. He is in a regular classroom with accommodations. While at school, he receives occupational and speech therapies and has a personal care aide. He is totally dependent for all age appropriate activities and tasks, and requires maximal assistance for all personal care tasks (bathing, personal hygiene, toileting). 

Personal care needs include all activities of daily living, such as bathing, toileting, dressing, and personal hygiene. He is independent for ambulation and transfers, but with his lack of safety awareness, dangerous behaviors, and pica, he must be monitored at all times. 


The American Academy of Pediatrics (AAP) has published guidelines for home care of infants, children, and adolescents with chronic disease: "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens." Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities." (1) Finally, the AAP strongly supports preparing young people with special needs for the transition into adulthood: "the goal is to maximize lifelong functioning and potential through the provision of high-quality, developmentally appropriate health care services that continue uninterrupted as the individual moves from adolescence to adulthood." (2)

This male teen with autism and significant psychiatric and behavioral issues requires maximal assistance for all activities of daily living and is fully dependent for age appropriate functional activities. He requires constant supervision because of his lack of safety awareness, destructive behaviors, and pica. His parents are both primary caregivers, but his father works one part-time and one full-time job outside of the home, and his mother manages the household and cares for four children all of whom have special needs. It is neither safe nor appropriate for her to provide the constant supervision and assistance that this child requires because of her other family/household obligations. The requested 21 hours of consumer directed personal care assistance are medically necessary and appropriate to provide the patient with the constant supervision and support that he requires.