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

The parent of a three-year-old male enrollee has requested speech therapy five hours a week (home based), physical therapy one hour a week, and occupational therapy two hours a week for treatment of the enrollees autism.  Findings:  The physician reviewer found that 1. Is speech therapy for five hours a week (home based) medically necessary? The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have autism spectrum disorders. In this particular case, the patient suffered a left frontal lobe stroke which in 95% of the population is the dominant hemisphere and controls Brocas area which is essential for speech. Thus, in addition to speech and language delays associated with a diagnosis of autism, this patient has an acquired apraxia that requires speech therapy.The severity of both acquired and developmental apraxia of speech varies from person to person. The present literature about childhood speech apraxia indicates an inclination toward a mixed therapeutic approach, which includes aspects pertinent to language processing in a phonological representational level as well as aspects related to motor programming and pre-articulatory sequencing of speech itself. Research shows that children with developmental apraxia of speech have more success when they receive frequent (3-5 times per week) and intensive treatment. As the patient improves, he or she may need treatment less often.In the case of this patient, speech therapy at a frequency of five times per week (in home) is medically appropriate and clinically indicated given the patients documented developmental delays and apraxia. The patient should be re-evaluated in three months to determine if this frequency of therapy continues to be medically necessary.2. Is physical therapy for one hour a week medically necessary? The American Academy of Neurology and Child Neurology Society guidelines on autism state The immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators.  The guidelines further indicate that 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. In the case of this patient, his provider has identified functional deficits that are likely to benefit from physical therapy at a frequency of one hour per week. Therefore, the requested physical therapy services are medically indicated and necessary for this patient.3. Is occupational therapy for two hours a week medically necessary? The prevalence of impairments in fine and gross motor skills in patients with autism and pervasive developmental delay appears to be relatively high. Occupational therapists work as part of a team that includes parents, teachers, and other professionals. To support the need for occupational therapy, studies have shown benefits that prevent a deterioration or reversal of function as well as a significant improvement in activities of daily living. An article by Thomas, et al. indicates that occupational therapy addresses deficits such as poor trunk stability, reduced muscle tone, poor endurance, tactile defensiveness, proprioceptive processing issues, and cognitive impairments that are associated with motor skills development in children with Fragile X Syndrome. Such deficits are also found in patients with autism. In addition, occupational therapy combined with speech therapy can focus on oral-motor intervention to reduce tactile sensitivity and increase muscle tone in order to enhance language development. Thus, occupational therapy at a frequency of two hours a week is a medically necessary modality for this patient with autism.