Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder, Attachment Disorder, Anxiety Disorder, and rule out Autism Spectrum Disorder.

Treatment: Personal care services (PCS).

The insurer denied coverage for PCS.

The denial is upheld. 

This patient is a female child with attention and behavioral symptoms, and social delays who was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder, Attachment Disorder, Anxiety Disorder, and rule out Autism Spectrum Disorder.  The patient was noted to have oppositional and defiant behavior, was easily annoyed, blamed others, had difficulty paying attention, had disorganization, was losing things and forgetful, talked excessively, and interrupted others.  The patient reportedly had sensory aversions, did not pick up on social cues, did not initiate friendships or have friends, lacked interest with peers, and preferred to be alone. The patient had court system involvement due to witnessing domestic violence and did not have visitations with her father.  The patient was taking Daytrana prescribed by her Psychiatrist.  The patient's medical history was significant for sleep apnea for which she had her tonsils removed, and a history of pneumonia, urinary tract infections, and bed-wetting.   The patient's mother is seeking personal care services (PCS) to help the patient. 

The Department of Health reports that PCS helps people with everyday tasks including activities of daily living (ADL's) or household tasks.  It also states that personal care attends 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 did not have reported difficulties ambulating, bathing, showering, brushing her teeth, transferring from the tub or shower.  The patient had reports of behavioral and attention symptoms ADHD symptoms and was taking psychotropic medication, Daytrana, to help target this.  

The American Academy of Child & Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention Deficit Hyperactivity Disorder does not mention personal care assistance services as a standard for treatment.  It mentions pharmacotherapy and also behavioral therapy and parent training as standards of treatment.  Also in order to meet criteria for PCS, these services must be essential to maintenance of the patient's health and safety in his or her own home.  The service must be based on the assessment of the patient's need and must meet requirements for PCS and must be considered medically necessary services.  The submitted medical records did not provide enough specific evidence to support that PCS was considered medically necessary for this patient. 

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

The carrier's denial of coverage for PCS should be upheld.  The medical necessity is not substantiated.