Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Autism Spectrum Disorder.
Treatment:  Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 70 Hour(s) per Week.

The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 70 Hour(s) per Week.  The determination is overturned in part.

This is a male patient with a medical history notable for mitochondrial complex 1 deficiency, autism spectrum disorder, and prior testicular cancer in remission. The patient is approved for 35 hours per week of level 2 personal care services. The patient and his care team requested an increase to 70 hours per week, and the request was denied by the health plan.
Hospital records were provided for review. The patient was admitted from for therapeutic intravenous (IV) ketamine infusions for symptoms of psychosis. Discharge notes state that the patient at baseline is dependent on his family for activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The infusions were not tolerated. Office visit notes from his neurosurgeon were also provided and reviewed. There were no letters of medical necessity provided as part of this review.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives with his parents in an apartment. He receives consumer directed personal care. The patient was alert but disoriented with periods of confusion noted. He is not able to direct his own care. For his Instrumental activities of daily living (IADL), he requires total dependence for almost all. For his activities of daily living (ADL), he requires maximal assistance for bathing, dressing, hygiene, and toilet use. He requires extensive assistance for walking, locomotion, toilet transfer, and eating. He requires limited assistance for bed mobility. He is continent of urine and stool. A task tool associated with the assessment recommended 51.92 hours per week to address his personal care needs. At issue is the medical necessity of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 70 Hour(s) per Week.

The requested health service/treatment of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 70 Hour(s) per Week has not been demonstrated to be medically necessary for this patient.
However, the patient's personal care needs are extensive, and he requires assistance with all ADLs and IADLs. The task tool recommends 52 hours per week to address his needs, and this is medically necessary. Because he receives consumer directed care, his family can direct these hours as needed for the patient.
There is insufficient evidence that the requested increase to 70 hours per week is medically necessary. There were no letters provided describing why this increase over the task tool recommendation is required. It has not been clearly demonstrated that 70 hours per week is required for the patient.

The health plan's determination of medical necessity is overturned in part. 52 hours per week of consumer directed personal care as recommended by the most recent task tool assessment is medically necessary.