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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for the Recommendations from the second Occupational Therapy Screening report: Direct individual occupational therapy is recommended at a rate of 120 minutes once per week or two 60-minute sessions. Findings:  The physician reviewer found that tandardized testing is recommended to determine baselines for specific goals based on areas of need. Therapy is recommended for a period of three months with a progress update at that time to determine continued need for occupational therapy services. Occupational therapy is generally recommended for children with autism spectrum disorder. Hyman and colleagues report, Occupational therapy services may be indicated to promote fine motor and adaptive skills, including self-care, toy use, and handwriting. Almost two-thirds of preschool-aged children with autism spectrum disorder are reported to receive occupational therapy services.` However, there is a lack of data in current medical literature supporting 120 minutes weekly of therapy over the 60 minutes weekly that the patient is currently receiving or any specific guidelines regarding the dosing of occupational services. There is significant controversy in current medical literature on the effectiveness of sensory integration therapy. Sensory integration therapy is usually provided by occupational therapists and may be provided in various forms, often in combination with purposeful muscle activities, with the goal of improving how the brain processes and organizes sensory information. The American Academy of Pediatrics position reports regarding the use of sensory integration therapies for children with developmental and behavioral disorder that parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive. In a systematic review of the effectiveness of sensory integration therapy, Watling and Hauer report moderate evidence to support the use of Ayres Sensory Integration within the scope of occupational therapy to improve performance, noting that the results for sensory-based methods was mixed and that further research with higher level studies with larger samples are recommended. Leong and colleagues note the controversial nature of the use of sensory integration therapy, concluding in a systematic analysis on the outcomes of 17 single case design studies that there was a lack of convincing evidence for the effectiveness of sensory integration therapy. The authors further noted that its use should be limited to experimental contexts. In a practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder, the American Academy of Child and Adolescent Psychiatrists (AACAP) Committee on Quality Issues notes that studies of sensory oriented interventions, including auditory integration training and sensory integration therapy, have contained methodologic flaws and have yet to show improvements that can be replicated. In this patients case, the requested services are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, the Recommendations from the second Occupational Therapy Screening report: Direct individual occupational therapy is recommended at a rate of 120 minutes once per week or two 60-minute sessions. Additional standardized testing is recommended to determine baselines for specific goals based on areas of need. Therapy is recommended for a period of three months with a progress update at that time to determine continued need for occupational therapy services are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology 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.