Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder
 
Treatment: Increase in Consumer Directed Personal Care Assistance services from Level ll services 3 hours per day, 7 days per week, total of 21 hours per week to 7 hours per day, 7 days per week (Monday through Sunday), total of 49 hours per week.

The insurer denied the Increase in Consumer Directed Personal Care Assistance services from Level ll services 3 hours per day, 7 days per week, total of 21 hours per week to 7 hours per day, 7 days per week (Monday through Sunday), and total of 49 hours per week. The denial was reversed.  

This is a young male patient with a history of Autism Spectrum Disorder. He had developmental delays in social communication and social interaction. He was nonverbal but responded to facial expression, gestures, and his mothers' voice.  His behaviors included jumping in place and rocking in the past to the point of breaking furniture. Past self-injurious behavior included hitting his head to the wall. He was receiving personal care assistance (PCA) 3 hours a day 7 days a week. Due to the increased assistance required for him to function with his activities of daily living (ADLs), an increase in more PCA was requested. 

The American Academy of Child and Adolescent Pediatrics (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Autism and Other Pervasive Developmental Disorders reports that some patients with autism and developmental delays have severe deficits in adaptive functioning and require assistance for activities of daily living, supervision for safety, and for structure as they often require intense sustained structure due to their delays. It appeared that he needed more than just 3 hours per day of personal care services as it was reported by his doctor that he needed more assistance. It was reported that since he was a teenager, it was difficult for his mother to assist with walking, sitting, toileting, housekeeping, and meal preparation. He had cognitive limitations preventing the completion of ADL's without assistance. He was unable to walk without assistance, was too hyperactive to pay attention to his path, and would trip and fall on obstacles such as furniture if not assisted. Also, he would attempt high speeds in small places and crash into walls, he lacked the ability to make decisions on transferring from sitting to standing to walking and vice versa, could not appropriately judge how to sit on furniture, could not complete toileting without prompting and reminders, did not know the dangers of falling in a bathroom, so he should not be left alone, needed assistance to bathe, groom, and dress, needed all meals prepared for him including a special diet due to his texture sensitivity, needed prompting and cuing in eating, including using utensils and eating slowly, and this often could take over 1 hour, and he needed to be accompanied to his appointments and other places.

These needs reportedly required at least 7 hours per day of direct personal care assistance. Autism spectrum disorder is a neurodevelopmental disorder that is considered permanent and there are many associated deficits with this disorder so the needs for patients with these disorders and developmental delays can be extensive, which is the case with this patient. 

Based on the above, the medical necessity for an increase in Consumer Directed Personal Care Assistance services from Level II services 3 hours per day, 7 days per week, total of 21 hours per week to 7 hours per day, 7 days per week (Monday through Sunday, total of 49 hours per week) is substantiated.  The insurer's denial is reversed.