Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism spectrum disorder (ASD)

Treatment: Consumer directed personal assistance services (CDPAS)

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

The denial is upheld

 
Per office notes, a board-certified developmental-behavioral pediatrician diagnosed him with autism spectrum disorder (ASD) and global developmental delay. There is no documentation of his performance on standardized testing of intelligence or adaptive skills. The request is for personal care services (PCS) with no mention of the number of hours per day or week. There is no documentation of the goals for PCS (i.e., what this service is targeting). Note: for this patient personal care service PCS is referred to as "consumer-directed personal assistance services (CDPAS)".

Per assessment the CDPAS will be a family member. Mother will provide direct care. Child resides with mother who  works full time. Father is hardly involved to assist with child's care needs due to work. As per mother, child has not started school yet. Child has no physical therapy (PT)/ occupational therapy (OT)/Speech services in place. Child walks with a steady gait. Child is able to feed himself but requires supervision. 

Personal care services (PCS) (in this case, called CDPAS) are medically necessary if they meet the following criteria:

The patient is impaired in at least two ADLs as determined by standardized testing (e.g., Vineland Adaptive Behavior Scales, Third Edition (Vineland-3), Adaptive Behavior Assessment System, Third Edition (ABAS-3), or equivalent tool) with a standard score < 70 based on input parents and teachers [Not met. The clinical records provided do not substantiate this.]

o	Bathing
o	Dressing
o	Using the toilet
o	Transferring (to or from bed or chair)
o	Caring for incontinence
o	Eating

The services relate to physical requirements, when physical limitations are due to illness, injury, developmental delay, or developmental disability requiring assistance with activities of daily living (ADLs) such as eating, bathing, dressing, personal hygiene, and bladder or bowel requirements. [Not met. The clinical records provided do not substantiate this.]
Without these services, the patient would require intermediate care facility (ICF) or equivalent level of care (e.g., day resident program) [Not met. This patient is not at risk for institutionalization.]
The services enable the recipient to be treated on an outpatient basis rather than an inpatient basis to the extent that services on an outpatient basis are projected to be more cost effective than services provided on an inpatient basis [Not met.  The patient does not require inpatient services.]
 Parent, guardian, or caretakers are physically unable to provide personal care services [Not met. This is not documented.]
The services are not to be provided to meet childcare needs or as a substitute for the parent in the parent's absence [Not met. This appears to be a substitute for the parent.]
The services are provided by a qualified individual who is not part of the member's family or household [Not met.  It appears that the CDPAS provider is the child's grandmother.]
The services cannot be met by other resources such as respite care or private duty nursing [Not met.  Respite care can achieve the same goals.]
 Other family members are not available to perform these duties [Not met. This is not documented.]
 Requested services do not function as a substitute for routine adult or child daycare [Not met. This is not documented.]
Requested services do not function as respite care for parents or caregivers [Not met. This is not documented.]                                                         

Based on the above, the insurer's denial must be upheld. The health care plan did 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) services is not substantiated.