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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for (1) speech therapy services: one hour five times a week and (2) occupational therapy services: two hours three times a week. The submitted documentation supports the medical necessity of a portion of the requested services. The American Academy of Pediatrics guidelines on the identification, evaluation, and management of children with autism spectrum disorder (ASD) describes delayed language as an early concern for many children who are later diagnosed with ASD, and that the communication symptoms included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for ASD reflect core deficits in social communication and interaction including failure of back-and-forth communication, deficits in nonverbal communication such as eye gaze and use of gesture, difficulty adjusting behavior to suit the social context, and restricted and repetitive behaviors leading to perseverative vocalization, echolalia, and preoccupation with restricted topics of interest. While the guidelines note that speech-language therapy is the most commonly identified intervention provided for children with ASD, they do not specify optimal intensity/dosage of speech therapy. In an examination of treatment intensity delivered to 223 children with language impairment, Schmitt and colleagues concluded that the findings suggested that more intensive language treatment, measured as time, was not necessarily associated with better treatment outcomes. In an examination of the association between dose, intensity, and effect size in 20 randomized controlled studies taken from a few systematic reviews focusing on interventions aiming to ameliorate vocabulary, phonology, and syntax, Zeng and colleagues reported, Dosage, however defined, is not directly associated with outcome, although the level of association varies across the three interventions, for example appearing stronger for vocabulary and phonology than syntax. The authors concluded, Given the available data, it is not, at this stage, possible to make recommendations about optimal dosage. In a study synthesizing the effects of interventions on language outcomes of children up to eight years of age with autism and evaluating the extent to which summary effects varied by intervention, participant, and outcome characteristics, Sandbank and colleagues found that the summary effect of intervention on language outcomes was small but significant, and that effects were not moderated by cumulative intervention intensity or intervention type. Hyman and colleagues note that children with ASD may have low muscle tone or a developmental coordination disorder, and that while the ages for sitting and walking do not differ between children with ASD and children with typical development, both fine and gross motor skills may be delayed in preschool-aged children with ASD. The authors further note that occupational therapy services may be indicated to promote fine motor and adaptive skills, including self-care, toy use, and handwriting. Bilaver and colleagues report that almost two-thirds of preschool-aged children with ASD receive occupational therapy services. Monz and colleagues note that the American Academy of Child and Adolescent Psychiatry recommends the use of multiple treatment modalities in ASD. While occupational therapy is generally accepted to be medically necessary in the treatment of ASD, there is a lack of evidence in current medical literature to support the optimal intensity and dosage of occupational therapy for children. In a meta-analysis using 123 pediatric occupational therapy outcomes studies from nine scholarly international occupational therapy journals, Gee and colleagues 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. In this case, the patient has a diagnosis of ASD. Children with ASD typically receive one to two sessions of speech therapy per week. In this patients case, (1) speech therapy services: one hour two times a week, and (2) occupational therapy services: one hour one time a week are medically necessary to prevent disease, disability, and other health conditions or their progression, to promote physical and mental health and efficiency and to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology with sub-specialty certification in neurodevelopmental disabilities 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.