Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for music therapy services. Findings:  The physician reviewer found that At issue is whether the requested music therapy services are medically necessary to treat the enrollees mental health or substance use disorder as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.The submitted documentation does not support the medical necessity of the requested services. There is currently insufficient evidence in current medical literature regarding the efficacy of music therapy in treating the symptoms of autism spectrum disorder (ASD). Using standard Cochrane methodological procedures to perform a meta-analysis of 26 studies involving 1,165 participants, on the short-term and medium-term effect of music therapy for autistic people in individual or group settings, Geretsegger and colleagues concluded, Music therapy is probably associated with an increased chance of global improvement for autistic people, likely helps them to improve total autism severity and quality of life, and probably does not increase adverse events immediately after the intervention. The certainty of the evidence was rated as moderate for these four outcomes, meaning that we are moderately confident in the effect estimate. No clear evidence of a difference was found for social interaction, non-verbal communication, and verbal communication measured immediately post-intervention. For these outcomes, the certainty of the evidence was rated as low or 'very low. The authors noted that five of the studies included children and adolescents, and/or young adults, and that severity levels, language skills, and cognition were widely variable across studies. In a systematic review of 39 studies involving 1,774 participants with ASD and other neurodevelopmental disabilities using two main music therapies, educational music therapy and improvisational music therapy, Mayer-Benarous and colleagues reported, A positive effect of educational music therapy on patients with ASD was reported in most controlled studies, particularly in terms of speech production. A positive effect of improvisational music therapy was reported in most controlled studies, particularly in terms of social functioning. The subgroup of patients with both ASD and intellectual disability had a higher response rate. In a systematic review of interventions targeting sensory challenges in autism spectrum disorder, Weitlauf and colleagues concluded that the evidence base for any category of intervention was small, and the durability of the effects beyond the immediate intervention period was unclear. The authors noted that some positive effects were associated with music therapy, but findings in these small studies were not consistent, with insufficient strength of evidence, and that data on longer term results were lacking, as were data on characteristics that modify outcomes, effectiveness of interventions across environments or contexts, and components of interventions that may drive effects. Given that the strength of evidence supporting the use of music therapy in the treatment of ASD is, at best, only moderate regarding an improvement in a patients quality of life and total autism severity, with inconsistent findings in the small studies published, along with insufficient data on long-term effects, the requested services are not medically indicated. Therefore, the requested music therapy services are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested music therapy services are not clinically appropriate in terms of type, frequency, extent, site, and duration.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology with sub-specialty certification in neurodevelopmental disabilities and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.