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

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement and prospective authorization and coverage for sensory integration therapy and authorization and coverage for functional activity. In a review of sensory integration therapy, researchers found moderate evidence to support the use of ASI within the scope of occupational therapy to improve performance. However, the authors noted that the results for sensory-based methods are mixed and further research with higher level studies with larger samples are recommended. The American Academy of Pediatrics (AAP) discussed the prescription of occupational therapy to children with delayed fine motor skills in guidelines. The AAP states that various forms of sensory stimulation are provided, often in combination with purposeful muscle activities, with the goal of improving how the brain process and organizes sensory information. Overall, there is a lack of data in the peer-reviewed medical literature and clinical guidelines to support use of sensory integration therapy for treatment of this patient. With regard to functional activity, the patient has delayed fine motor skills, and decreased arm strength as evidenced by her delay in self-care skills and inability to engage in age-appropriate play. The providers notes describe the functional activity therapy sessions include crossbody activities such as placing coins in a bank, peg boards, knob puzzles and squeezing PlayDoh, all of which are aimed at improving the patients arm and hand strength and coordination and improving her fine motor skills. Given these findings, the requested functional activity is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while the sensory integration therapy was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found a portion of the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the requested services is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics with subspecialty certification in pediatric critical care medicine and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certification in pediatric critical care medicine and is actively practicing. Physician reviewer 3 is board certified in neurodevelopmental disabilities with subspecialty certification in neurology with special qualification in child neurology and is 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.