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

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee has requested reimbursement and prospective authorization and coverage for occupational therapy with sensory integration therapy services provided in the months of July and August of 2021 and forward.Findings: Two out of three medical experts decided that occupational therapy with sensory integration therapy services provided in the months of July and August of 2021, and forward were and are likely to be more beneficial for the enrollee than any available standard therapy.Children with sensory integration/modulation disorders (SID) present with delays or inability to meet expected milestones in different domains of development. Additionally, they have behavioral, sleep and psychological issues that are problematic in home and school settings. As a result, researchers state that a multidisciplinary team involvement, including neuropsychology, physical, occupational and speech therapy, and social work, is essential to maximize the quality of life and well-being for patients with SID and their family. The authors also indicate that acquisition of effective motor skills is relevant for several everyday abilities, such as language and communication, academic learning, social interaction, and self-care activities, such as feeding, dressing, and grooming. Functional impairments can limit a childs ability to participate in age-appropriate and meaningful activities of childhood. World Health Organizations International Classification of Function (ICF) model recommends therapeutic intervention for children with disabilities that include a systematic assessment of the physical and cognitive abilities with an emphasis on how best to improve participation in all aspects of life. Occupational therapy (OT) is the discipline that trains children to effectively interact with their environment and engage in desired daily activities. The potential benefits of OT are well-defined and include: stimulation of vocalization and language; improved toleration and processing of touch, sound, visual and vestibular stimuli; improved self care, and upper extremity motor coordination. These benefits may have holistic effects and hence translate to improved relationships with peers and family members and increased social acceptance, improved motor skills and safety with everyday activities of daily living. In this case, the patients developmental  limitations compromise his independence and participation in activities of daily living. Therefore, occupational therapy with sensory integration therapy services provided in the months of July and August of 2021, and forward were and are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were and are likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1 and reviewer 2 are board certified in neurology with special qualification in child neurology. Reviewer 3 is board certified physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation medicine. All reviewers are actively practicing. The reviewers are experts 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.