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 occupational therapy services, once a week. The submitted documentation fails to demonstrate the medical necessity of the requested services. The in-network occupational therapist has recommended twice monthly sessions for 12 weeks to address the patients difficulties with self-help skills (using utensils for eating, toileting and tying shoelaces), with re-evaluation at the end of that time to assess whether additional sessions are necessary, dependent on progress towards goals. The patients parents have attended a home sensory skills program and have received advice regarding implementation of a home program. The patient was noted to have above average fine motor precision, average fine motor integration, and above average manual dexterity on the Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition (BOT-2). He exhibited good bilateral hand control, using his hands to stabilize paper when cutting and drawing, and using both hands to string beads. The out-of-network occupational therapist recommended therapy for sensory-motor differences to address sensory processing disorder. The American Academy of Pediatrics does not endorse sensory integration therapy. Gee and colleagues published a meta-analysis using 123 pediatric occupational therapy outcomes studies from nine scholarly international occupational therapy journals. The parameters of dosage were calculated using descriptive statistics in order to obtain a representation of dosage available within the current collage of pediatric occupational therapy outcomes studies. The results revealed that most studies reported portions of dosage parameters within the published studies. The authors concluded, Evidence is lacking within the published literature to adequately guide occupational therapy dosage decisions. Further research related to dosage in pediatric occupational therapy practice is needed.Sensory integration therapy is usually provided by occupational therapists. Various forms of sensory stimulation are provided to the patient, often in combination with purposeful muscle activities, with the goal of improving how the brain processes and organizes sensory information. Sensory integration therapy has been a popular treatment for children with neurodevelopmental disorders (such as ADHD, autism, and developmental delay), but there is significant controversy regarding its effectiveness. As noted by Zimmer and colleagues, the American Academy of Pediatrics position statement indicates, Parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive. In a review of sensory integration therapy, Watling and Hauer found moderate evidence to support the use of Ayres Sensory Integration within the scope of occupational therapy to improve performance. The results for sensory-based methods were mixed. Further research with higher level studies with larger samples was recommended. Leong and colleagues noted that sensory integration therapy is a controversial treatment method that is widely used for people with disabilities. A systematic analysis of 17 single-case studies concluded there was a lack of convincing evidence for the effectiveness of sensory integration therapy.  Therefore, the requested occupational therapy services, once a week are not medically necessary for the treatment of this patient. 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 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.