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

This patient is a six-year-old male with the diagnosis of autism who received speech therapy, occupational therapy and applied behavioral analysis through the local Regional Center until age three.  He has been receiving private pay therapies since that time.  It is unclear what services have been provided to the patient through the school system.  An Autism Evaluation was performed through the Health Plan in September 2005. The recommendations at that time were to contact the local school district to receive an applied behavioral analysis program and to continue his current speech and occupational therapy through the local school district. The parents were also referred to a support group for autism.The parents have requested speech and occupational therapy for a combined total of 15 hours per week. The Health Plan denied the request based on a determination that the therapies are not medically necessary.In evaluating the medical necessity of the therapy services I reviewed the medical literature and found no clinically controlled studies that support or refute the efficacy of speech or occupational therapy in the treatment of autism. However, for many years these therapies have been considered an integral part of an overall autism treatment plan.  Based on long-term experience in treating children with chronic health care needs and clinical judgment, two essential considerations in determining the medical necessity of therapeutic intervention have been identified.  First, are the goals outlined in the therapy progress reports functional in nature or are they goals that would primarily be related to educational/learning issues?  Second, do the progress reports document gains over a reasonable amount of time? Given this is a chronic disorder, six months is a reasonable time frame.Speech therapyThe progress report dated February 2006 stated goals of (1) increased social interactions (appropriate yes/no response); (2) increased dyad communication; and (3) increasing receptive understanding to one-step commands.  Although these goals are very broad and should be better defined, they are functional goals involving skills needed to function in everyday society.  The scope of the skills extends beyond the classroom and is not exclusively related to educationally based activities (e.g. grammar skills, writing skills, developmental articulation issues). With respect to the documentation of functional gains, true baseline data was not provided, however the most recent report documents the achievement of goals established in the previous evaluation period.  Therefore, I consider the speech therapy as provided, (four times per week) medically necessary.  Future goals should be more specific and directed toward the integration of the patient into society (pragmatic communication skills) and evaluated at six-month intervals in terms of a quantifiable goal attainment scale.  Occupational therapyIn the progress report dated February 2006 the goals of the therapy are poorly outlined and are divided between educationally based goals and functional goals.  Clearly, dressing skills (donning and doffing socks, buttoning buttons) are functionally based goals, while imitating a line and decreasing self stimulation are more related to behavior and educationally based therapy. The progress report and daily notes provided do not adequately document improvement in function over the three-month period that was evaluated. Without documentation of the baseline level of function and achievement of identified functional goals over a reasonable time period, I consider the medical necessity for occupational therapy has not been established.  Based upon the information set forth above, I have determined a portion of the requested therapies is medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.