Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism. 
Treatment: Occupational therapy services. 

The insurer denied coverage for occupational therapy services. 
 
The denial is overturned. 

This case involves a male diagnosed with autism who received occupational therapy services who demonstrated impairments in fine motor skills and activities of daily living. Reports stated that the patient required maximum assistance from his caregivers to complete daily functional tasks. The patient received a notice of adverse determination claiming that the therapy services in question were not supported as the patient's function had achieved maximum therapeutic benefit with the treatment plan. An appeal was submitted on to claim that the patient continued to struggle with independent living skills such as handwriting, opening food packages, opening water bottles, and with other daily living activities. The treating physician stated the patient required ongoing assistance with all activities of daily living that required fine and gross motor coordination, which was affecting him both at home and in school. It would be essential that the patient continue to receive services to help him function independently. 

The healthcare plan did not act reasonably and with some medical judgment and in the best interest of the patient. 

The occupational therapy services were considered medically necessary for this patient. 

Literature notes that current treatments for autism spectrum disorder (ASD) seek to reduce symptoms that interfere with daily functioning and quality of life.  Treatments are generally broken down into categories that address behavioral, developmental, educational, social-relational, pharmacological, psychological, and complementary and alternative needs. In the case of this patient, records noted that while the patient had previously received occupational therapy and benefited from the services, he continued to have impairments with fine and gross motor coordination, which was affecting his ability to function at home and in school. In taking the patient's age into consideration, and evidence noting that autism can and will likely affect the patient throughout the course of his lifetime, continued treatment with occupational therapy would be beneficial in helping the patient to gain independence, which can help to lead a more effective lifestyle as he ages. Occupational Therapy teaches skills that help people live as independently as possible and may include dressing, eating, bathing, relating to people, along with sensory integration therapy, which can help improve responses to sensory input that may be restrictive or overwhelming, and physical therapy, which can help improve physical skills, such as fine movements of the fingers or larger movements of the trunk and body. In taking this information into consideration, and the information submitted by the treating physician, it was determined at that therapy should be individualized to meet the needs of the patient. Therefore, it was determined that occupational therapy services were considered medically necessary for this patient. The prior determination is overturned. 

The insurer's denial of coverage for occupational therapy services is overturned. Medical Necessity is substantiated.