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

Nature of Statutory Criteria/Case Summary: the parent of a 13-year-old female enrollee has requested authorization and coverage for neuro-processing disorder evaluation and health care services; auditory processing disorder evaluation and health care services; sensory processing disorder evaluation and health care services; primitive reflex vision disorder evaluation and health care services; and optometric vision therapy. Findings:  The physician reviewer found that the patient has severe limitations in speech, which is limited to a few words, and intellect. Per the record, attempts to test the patient for auditory processing disorder could not be completed due to the patient's inability to follow rudimentary directions.  The patients parent has requested multiple therapeutic tests and interventions to determine and improve the patients functional skills. These sensory processing modalities include auditory visual motor reflexes, primitive reflex disorders, neuron sensory disorders, and auditory processing disorders. The patient has had two cerebral magnetic resonance imaging (MRI) scans which demonstrated frontal and thalamic gliosis and a small brain stem.  The parent believes that some of these requested therapies will result in physical improvement in the brain stem. The patients parent requested coverage for neuro-processing disorder evaluation and health care services; auditory processing disorder evaluation and health care services; sensory processing disorder evaluation and health care services; primitive reflex vision disorder evaluation and health care services; and optometric vision therapy. While the concept of improving disabilities with sensory processing therapies has many adherents, the medical evidence has not proven the efficacy of such tests in this clinical setting. In this case, this patient functions below the capabilities of many children with Down syndrome. According to Council on Children with Disabilities, the concept of improving both motor and intellectual functions with sensory stimulation was introduced in the 1970s.  However, there has been a lack of medical evidence in rigorous controlled studies to indicate the efficacy of sensory processing therapies.  Potier and Reeves state that intellect improvements, for those with Down syndrome, tend to plateau or deteriorate as they get older.  Additionally, executive function tends to deteriorate with aging. The medical literature also indicates that improvement in language ability is only apparent in high functioning Down syndrome patients.  Based on the submitted documentation, this patient has a very limited prognosis to improve her speech.  As such, the limited available medical literature implies that sensory processing therapies are not likely to be as effective as other modes of therapy for the evaluation and treatment of this patients medical condition. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: all three physician reviewers are board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.