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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for feeding therapy, occupational therapy, and an increase of one hour of speech therapy per week (total two hours per week). Findings:  The physician reviewer found that this patient presents with a reported diagnosis of autism spectrum disorder. The patients parent has requested feeding therapy, occupational therapy and an increase in speech therapy from one hour per week to two hours per week. Houtrow and colleagues noted that, the efficacy of therapy services to help children gain and/or maintain function and provide adaptations is well documented. Provision of a home program with caregiver training and support is generally indicated, because carryover of skills is enhanced by frequent repetition. This patients providers have recommended a home program and classes aimed at ameliorating the patients sensory and feeding problems, which is adequate given the patients diagnosis of autism spectrum disorder. The records do not support a current indication for feeding therapy. Tan and colleagues described that severe feeding disorders and food aversion can result in malnutrition in children with autism spectrum disorder. In this case, the provider recommended the patient follow-up with his primary care provider for evaluation. There are no records documenting that the patient followed-up with his pediatrician as recommended for evaluation to assess whether feeding therapy is indicated. Feeding therapy may be appropriate if the patients provider finds that the patient is losing weight or is at risk of nutritional deficiencies. Based on the available documentation, the requested feeding therapy is not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, the requested feeding therapy is not medically necessary for treatment of this patient. Addressing the request for occupational therapy, this patient presents with significant sensory issues, and borderline fine motor/self-help skills. Thus, occupational therapy is appropriate and medically necessary. The patients provider has recommended that the patients treatment regimen include parent classes, a home occupational therapy program, and occupational therapy collaboration with an ABA team, which is consistent with current recommendations and guidelines. The patients mother reports that the patient was approved for 20 hours of ABA services, yet they are only using 11 of those approved hours. Full use of the approved ABA hours would be beneficial for the patient. Continued occupational therapy should be contingent on these measures being in place. Per the American Academy of Pediatrics (AAP) guidelines, occupational therapy services may be indicated to promote fine motor and adaptive skills, including self-care, toy use, and handwriting (Hyman, et al.). Bilaver and colleagues reported that almost two-thirds of preschool-aged children with autism spectrum disorder receive occupational therapy services. For these reasons, the requested occupational therapy is in accordance with the generally accepted standards of mental health and substance use disorder care and is medically necessary for treatment of this patient. Speech therapy is medically necessary for this patient. However, there is insufficient evidence to support an increase to include two one-hour sessions per week. Houtrow and colleagues noted that, Determining the appropriate dose of therapy (how much therapy, how often, and for how long) remains elusive and largely subjective. The authors found that, Because of their attention spans, young children usually do well with shorter duration of therapy per session and, therefore, may need more total sessions or breaks within sessions. This patients records document progress with speech therapy in receptive and expressive language, and in social-pragmatic language. There is a lack of support to increase the total number of speech therapy hours per week in this clinical setting. Accordingly, the requested increase of one hour of speech therapy per week (total two hours per week) is not clinically appropriate in terms of frequency, extent, and duration. Given these findings, the requested occupational therapy is medically necessary for this patient, while the requested feeding therapy and an increase of one hour of speech therapy per week (total two hours per week) are not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology 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.