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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for three (3) sessions per week of speech therapy co-treatment with occupational therapy, one (1) session per week of speech therapy co-treatment with a behavior technician and one (1) session per month of speech therapy co-treatment with a BCBA. The enrollee has autistic disorder and speech/language delay and receives speech therapy (ST) and occupational therapy (OT). Concerns are related to motor planning/coordination skills and sensory processing differences affecting activities of daily living (ADL) independence. The enrollee is showing measurable gains by his continued progress with goal areas and increased independence in self-care skills. The ST re-evaluation report indicates the enrollee started therapy with two times per week for 30 minutes. The enrollee does not like structured ST in the speech rooms and gets upset if he is not in the OT gym. His occupational therapists indicate the enrollee is always happy in the gym and is more communicative. It was recommended ST sessions co-treat with OT, where the enrollee can work on building his utterance length by requesting preferable toys/activities, etc.    Records indicate he performs better when he is able to pick preferable activities and sessions are more functional. The decision was made to change his sessions to co-treatment with OT, where he can work on building his utterance length while requesting for preferable toys/activities. Typically, children on the autistic spectrum require interventions in multiple areas; including speech therapy, occupational therapy, and behavioral therapy. Therapists experienced with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate. Deficits in communication are integral to the diagnosis of autism and are the foundation for many of the clinical findings. The sooner and more aggressively these deficits are addressed, the better chance the child has for developing adequate skills to function in the community. It is medically necessary for the enrollee to have three sessions of speech therapy co-treatment while in occupational therapy. Speech therapy co-treatment with occupational therapy will facilitate management of behavioral issues. The records indicate the enrollee has not participated well with ST in the treatment room, but has good participation in conjunction with OT in the gym. Many therapists and researchers see OT as the initial stepping stone to advancing the STs ability to treat and expand communication systems. For some children with ASD and challenging behaviors, sensory-based intervention is a prerequisite to functional communication training. The speech therapist provides support to the OT and the enrollee to assist the enrollee in knowing when he will get his sensory needs met or get relief from overwhelming sensory input. Once the enrollee is ready, other communication expectations can be met. Additionally, one (1) session per week of ST co-treatment with a behavior technician will help address the enrollees problem behaviors while completing speech therapy. The goal is for the enrollee to decrease maladaptive behaviors and to increase engagement with the speech therapist. The role of the behavior technician is to provide recommendations on how to decrease unwanted behaviors. Finally, one (1) session per month of speech therapy co-treatment with a BCBA is not medically necessary as the BCBA serves in a supervisory role and does not need to work directly with the enrollee once a month. Final Result: The reviewer determined that the requested services are partially medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pediatric rehabilitation medicine 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 similar medical condition.