Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a nine-year-old female who presents with various diagnoses including autism, post-traumatic encephalopathy, static encephalopathy and attention deficit disorder. She has also been diagnosed with verbal dyspraxia. The patient has been receiving occupational therapy including sensory integration therapy with some improvement. The Health Plan has denied authorization for continued occupational therapy on the basis it has not been shown to be efficacious for patients such as this patient.Autism is a complex, difficult disease. There are many treatment modalities, but few are universally accepted. Occupational treatment including a sensory integration component is a reasonable treatment approach for this patients diagnoses. Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a nine-year-old female with a history of autism and hypotonia who has been receiving occupational therapy since September 2003. The therapy has included components of therapeutic exercise, neuromuscular reeducation, functional performance training, and sensory integration therapy. The therapist has documented gains in fine and gross motor activities; specifically, the patient has improved in her ability to use her upper extremities at midline. In addition, balance and coordination have improved with her ability to bounce on the trampoline. At issue is whether continued occupational therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.The therapy at issue has been described as sensory integration therapy. Upon review of the relevant literature, it is well documented that sensory integration therapy is the primary occupational therapy used in the treatment of children with autism. Though to date there are no long-term, randomized studies or outcome studies supporting sensory integration therapy as superior to standard therapy, there are short-term small-scale studies documenting its efficacy. A review of practice patterns of occupational therapists experienced in working with children with autism spectrum disorders revealed 99% of therapists surveyed used sensory integration therapy techniques in their patients with autism (Watling, et al.).With many of the treatments used in medicine, no randomized controlled studies exist but they are still considered standard of care. Sensory integration therapy is within the community standard for patients with sensory issues. It should also be noted the therapy at issue also includes therapeutic exercises and neuromuscular reeducation, which are types of standard therapy. The submitted documentation further reveals the patient is demonstrating functional improvement with the therapy. For these reasons, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: The patient is a nine-year-old female who has been receiving occupational therapy services for hypotonia and autism. The services are based on the theory of sensory integration. The Health Plan has denied coverage for continued occupational therapy on the basis the requested therapy is considered experimental.Occupational therapy is an accepted component of early intervention. The theory of sensory integration therapy is an unproven treatment modality. To date, there are no randomized controlled studies demonstrating the efficacy of sensory integration therapy. Though the patient appears to have a variety of issues and requires further therapy, there is insufficient evidence that the requested therapy is medically indicated. The patients ongoing issues should be addressed in an educational setting with supportive services. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.