Diagnosis: Autism

Treatment: Personal Care Assistance services for a total of 25 hours per week

The insurer denied coverage for Personal Care Assistance services for a total of 25 hours per week

The denial is upheld


The patient has been diagnosed with autism, and mixed expressive and receptive language deficits. It is noted the patient is currently taking medications for behavioral issues. It is noted that due to these issues, the patient requires home health aide. It is noted the patient can gesture to express needs and lives with a parent and sibling.

An assessment indicated the patient has no difficulty in normal conversation or social interaction and the patient was able to express herself and understand questions appropriately without difficulty. The most recent Uniform Assessment System (UAS) stated the patient is able to walk at least 150 - 299 feet without assistance. The patient did not cooperate with the Mini mental state exam. According to a recent physician progress note the patient attends school, and has an occasional manageable outburst related to autism. She is employed outside of the home.

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

Personal Care Assistance services for a total of 25 hours per week is not considered medically necessary for this patient.

There is no clear need, or objective deficits that would justify this level of care above supervision and care, which can be provided by the family. As such, the request is denied.

"When friends and family are unavailable or unable to care for homebound loved ones, primary care often deploys Home and Community Based Services, including home health aides. For these homebound older adults, home health aides are essential to help preserve an independent life at home and avoid nursing home care" (D'Cruz, L., et al. 2022).

To ensure optimal outcomes, decisions on and the delivery of health care services must focus on the child and family; be individualized to meet the child's needs; and cut across fragmented settings and service sectors to improve the child's health, functioning, and quality of life." (National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Improving Health Outcomes for Children with Disabilities. 2018).

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 Personal Care Assistance services for a total of 25 hours per week services is not substantiated.