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

The parent of a seven-year-old male enrollee has requested coverage for speech therapy twice per week and occupational therapy twice per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that the prevalence of impairments in fine and gross motor skills appears to be relatively high, based on the few studies that have included such information on patients with autism. Occupational therapists work as part of a team that includes parents, teachers, and other professionals. They help set specific goals for patients with autism. These goals often involve social interaction, behavior, and classroom performance. Occupational therapists can help in two main ways: with evaluation and therapy. To support the need for occupational therapy, studies have shown benefits that prevents a deterioration or reversal of function and a significant improvement in activities of daily living. Case-Smith, in 2008 evaluated six categories for the need of occupational therapy and showed that in all six areas occupational therapy significantly helped the patient. Another example of a patients own account of how occupational therapy improved his ability to perform activities of daily living over a five-year period was documented by Shoener. Overall, Case-Smith and Arbesman concluded that the research literature offers strong positive evidence for occupational therapists to use comprehensive, individualized analysis of the patients performance to develop the interven-tion strategies. The research evidence also supports the use of family-centered, interdisciplinary approaches. Many of the studies used play-based or activity-based interventions such as those implemented by occupational therapists.The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have autism spectrum disorder. In child development, delay in acquisition of speech is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. In the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary for this patient at the requested frequency of twice per week for 50 minute sessions.