Appeal type: Medical necessity
Decision: Overturned

 
Diagnosis: Autism Spectrum Disorder

Treatment: consumer directed personal assistance services (CDPAS)

The insurer denied coverage for consumer directed personal assistance services (CDPAS)

The denial is overturned

This patient has a diagnosis of Autism Spectrum Disorder (ASD) and has reported developmental delays and also has grand mal seizures, hypotonia, bladder problems including vesicoureteral reflux, and skin texture problems. The patient reportedly was living with their parents and attending a day program for special needs and had an aide there 5 hours 5 days a week. The patient reportedly was in early intervention. The recommendation was for consumer directed personal assistance services (CDPAS). It was reported that the patient's parents requested 30 hours per week of this service.
  
The insurer denied the request for consumer directed personal assistance services stating that it was not medically necessary services then. They stated that the patient could perform activities of daily living (ADL's) on their own and that the assessment did not show that the patient needed long-term care services.
 
The reviewer disagrees with the decision to deny coverage for consumer directed personal assistance services (CDPAS) as the medical records for review did support that the patient required this service. The Department of Health (DOH) reports that personal care services (PCS) help people with everyday tasks including activities of daily living or household tasks. It also states that personal care services attend to the physical needs of people disabled or otherwise unable to take care of themselves. Such ADL's include bathing, showering, management of bodily fluids, toileting, feeding, ambulating, transferring from bed to chair or wheelchair, or in and out of the tub or shower, grooming, taking care of teeth or mouth, housekeeping, or meal preparation. It involves a physician to order the services and then a nursing and/or social work assessment to be done. In this case, this patient has developmental delays and a diagnosis of Autism Spectrum Disorder as well as medical conditions including grand mal seizures, hypotonia, bladder problems including vesicoureteral reflux, and skin texture problems, and it was reported that the patient required assistance with activities of daily living. It was reported that the patient required full assistance with meal preparation including reading recipes, gathering ingredients, measuring ingredients, opening boxes, and pouring liquids. The patient reportedly required full assistance with ordinary housework and managing finances. The patient reportedly required some assistance with ADL's. The patient reportedly had difficulty making decisions and with self-direction and reportedly was forgetful with directions and had difficulty with multi-step directions. It was reported that the patient could not cook unassisted and required assistance with shaving and needed verbal reminders to take their anti-seizure medication, bladder medications, and creams for skin problems. The patient reportedly had difficulty processing and finding words and finishing thoughts. The patient reportedly required monitoring due to their seizures, especially at night as they could not be left alone. It was reported that the patient had blood after their first seizure. The patient reportedly required assistance making appointments, renewing medications, and arranging schedules. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for consumer directed personal assistance services (CDPAS) is substantiated.