Diagnosis: Autism spectrum disorder

Treatment: consumer directed personal care assistance services (CDPCAS), 40 hours per week

The insurer denied coverage for consumer directed personal care assistance services (CDPCAS), 40 hours per week.

The denial is upheld.

This patient is a male child with a history of autism as well as developmental delay and asthma. He does not communicate and is unable to express his needs. The child is rarely understood. The patient's mother reported that he has had pain issues such as screaming as well as hitting others and aggression. The patient's mother also indicated that he will wake up during the night, and had experienced repeated falls for his inability to stand still. He also requires assistance with activities of daily living and needs constant supervision. The patient continues to utilize diapers due to incontinence of urine and bowel movement. He was on a normal diet and participated in therapy services monthly. The patient also receives occupational therapy as well as speech therapy twice a week at school. The patient has been approved for 11 hours of consumer directed personal care assistance services (CDPCAS). The patient's mother is requesting an additional 29 hours of CDPCAS during the week; 40 hours per week.

The patient has a diagnosis of autism spectrum disorder. Documentation supported identifiable target behaviors having an impact on development, communication, and interaction with likely developing peers. The patient could not adequately participate in developmentally appropriate essential community activities. An individualized treatment plan that was child-centered and specific target behaviors were clearly defined. There were objective measurable goals and initial behaviors had been outlined. The central elements were met. There is no medical indication for CDPCAS. There is no literature to support improved evidence-based outcomes in children diagnosed with autism. The parent expresses some hardship with caring for her children and appears to seek respite services as an option for custodial care. However, as per Whitmore (2016), additional research is necessary to better understand the relationship between respite care and stress among caregivers of children with autism spectrum disorder. The patient currently receives 11 hours of CDPCAS services per week. There is no clinical support for increased hours of CDPCAS services for this patient. The requested service would therefore not be deemed medically necessary.

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

The carrier's denial of coverage for CDPCAS, 40 hours per week should be upheld. The medical necessity is not substantiated.