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 psychoeducational testing services to screen for learning disabilities and/or neuropsychological testing services to screen for pervasive developmental disorder. The records provided for review document that this patient has been assessed and diagnosed with attention-deficit/hyperactivity disorder (ADHD), combined subtype. Learning disabilities frequently co-exist with ADHD but are educational rather than medical in nature. Appropriate evaluation is performed by a psychologist, teacher, and often a speech-language pathologist as part of an individualized education plan (IEP) through the local school district. Interventions for learning disabilities are educational and implemented through the school. There is a lack of specific medical interventions for learning disabilities. The provider noted that the patient reverses letters, which is concerning for possible dyslexia. Researchers noted that developmental dyslexia is a specific and persistent disability affecting the acquisition of written language. The authors describe that a diagnosis rests upon the use of standardized tests and tools to assess reading and spelling, as well as phonological skills. Based on these findings, the requested psychoeducational testing services are not medically necessary to screen for learning disabilities are not to prevent disease, disability, and other health conditions or their progression; prolong life; promote physical and mental health and efficiency; or correct or ameliorate any physical or behavioral conditions. With regard to the requested neuropsychological testing services, pervasive developmental disorder was incorporated into the Diagnostic and Statistical Manual Fifth Edition (DSM-V) diagnosis of autism spectrum disorder in 2013. This patient underwent an evaluation with the ADOS-2 to assess for placement on the autism spectrum. Based on the patients history and direct evaluation on the ADOS-2, he did not meet diagnostic criteria for a pervasive development disorder. Additional testing is not indicated in this clinical setting. Therefore, the requested neuropsychological testing services are not medically necessary for this patient defined as needed to: (1) prevent disease, disability, and other health conditions or their progression; (2) prolong life; (3) promote physical and mental health and efficiency; or (4) correct or ameliorate any physical or behavioral conditions.All told, the requested psychoeducational testing services to screen for learning disabilities and neuropsychological testing services are not medically necessary for evaluation and 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.