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

The parent of a five-year-old female has requested speech therapy and occupational therapy for treatment of her autism.  Findings:  The physician reviewer found that on review of the medical literature, there is a relatively high prevalence of impairments in fine and gross motor skills in patients with autism. With regard to treatment, occupational therapists work as part of a team that includes parents, teachers, and other professionals to help set specific goals for the patient with autism. These goals often involve social interaction, behavior, and classroom performance. Occupational therapists can help in two main ways: with evaluation and therapy. To support the need for occupational therapy, studies have shown benefits that prevent a deterioration or reversal of function and a significant improvement in activities of daily living (Case-Smith and Arbesman). Case-Smith concluded that the research literature offers strong positive evidence for occupational therapists to use comprehensive, individualized analysis of the patients performance to develop the intervention strategies. The research evidence also supports the use of family-centered, interdisciplinary approaches. Many of the studies used play-based or activity-based interventions such as those implemented by occupational therapists. Specifically, occupational therapy typically addresses deficits such as poor trunk stability, reduced muscle tone, poor endurance, tactile defensiveness, and proprioceptive processing issues. In addition, occupational therapy combined with speech and language therapy can focus on oral-motor intervention to reduce tactile sensitivity and increase muscle tone in order to enhance language development. Evaluation of sensorimotor skills by a qualified experienced professional (occupational therapist or physical therapist) should be considered, including assessment of gross and fine motor skills, praxis, sensory processing abilities, unusual or stereotyped mannerisms, and the impact of these components on the autistic persons life. An occupational therapy evaluation is indicated when deficits exist in functional skills or occupational performance in the areas of play or leisure, self-maintenance through activities of daily living, or productive school and work tasks. Although not routinely warranted as part of all evaluations of children with autism, the Sensory Integration and Praxis Tests may be used on an individual basis to detect specific patterns of sensory integrative dysfunction. In child development, delay in acquisition of speech is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. In the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. All told, speech therapy is recommended for young patients with speech delay. The primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary for this patient.