Appeal type: Medical necessity
Decision: Upheld

Diagnosis:	Autism.	

Treatment:  Therapy Disciplines.

The insurer denied therapeutic activities.

The denial is upheld.

This is a child with a diagnosis of Autism. The patient has been receiving multiple forms of therapy since infancy and has gross motor, fine motor, and coordination deficits. Occupational therapy has been focusing on improving visual-motor, and sensory integration ability. The patient has shown improvement since the initiation of therapy disciplines. Ongoing therapy has been recommended. The request is for therapeutic activities for multiple dates.

"Difficulty with communication and social functioning are two outstanding core symptoms of autism spectrum disorder, while there is no efficacious pharmacologic treatment available to deal with them. Traditional behavioral therapies usually require specialist therapists and are conducted in specific settings, increasing burdens on families and individuals with autism. Physical activity has long been found to promote physical and mental well-being, and it is more affordable and versatile than traditional therapies. " (Chan, J.S., et al., 2021).

"Autism Spectrum Disorder (ASD) is a group of early-onset neurodevelopmental disorders associated with altered social communication and interaction, with repetitive stereotyped interest behaviors as core symptoms. A social communication disorder, characterized by persistent social communication and interaction deficits, is a core feature of ASD. These abnormal patterns can affect the development of social skills, preventing children from effectively participating in multi-context social interactions in the home, school, and community, with serious implications for survival and growth (2). In recent years, the global incidence of ASD has been rising. The prevalence of ASD in developed countries is approximately 1.5%, and according to the US Centers for Disease Control and Prevention, it was 2.47% in children aged 0-8 years in 2021. At present, there is no effective drug to treat ASD, and the function of existing drugs is limited to delaying the progression of the condition and alleviating the onset of social communication disorder in some autistic patients.
Physical exercise has increasingly been shown to improve core symptoms in patients with ASD. Individuals with ASD can participate in physical activity individually or in groups, and through watching and imitating their peers, they can learn social etiquette and social communication, and improve their visual processing ability and attention. This can ultimately improve cognitive function, and positively affect brain activation. Physical exercise can resemble stereotypical behaviors in individuals with ASD. Targeted activities can replace non-targeted stereotypical actions such that patients no longer need to experience pleasure from stereotypical behaviors. When playing ball games, the inevitable communication between children and their peers or parents can encourage children to engage in social activities. Similar findings have been reported for karate training. Children with ASD learn social communication by watching their peers, which emphasizes the importance of visual processing. In both laboratory and real-life social scenarios, an inability to establish eye contact with others severely affects communication in children with ASD. Sensory integration training can help improve visual processing skills in children with ASD and enhance their social processing abilities, thus promoting their social interaction skills. Basic social etiquette is also included in sports training, such as greeting peers, parents, or teachers during basketball training, queuing, etc., which increases communication, physical contact, eye contact, and language, and promotes social behavior in children with ASD.

In terms of social interaction, physical exercise is considered a safe and effective treatment option for improving core symptoms in patients with ASDs. Currently, there are no objective, effective, and specific early diagnostic biomarkers or drugs for the social problems associated with ASD, and medical needs are still not being met... Although physical activity does not address the core causes of this disorder, increasing physical activity levels may provide more opportunities for social interaction with peers, better attention and motor performance, and thus indirectly impact the core symptoms of ASD." (Jia, S. et al. 2023).

"Telerehabilitation services were rapidly implemented in three stages: building the foundation, implementing, and refining this service delivery model. Paper patient satisfaction surveys were administered as part of ongoing quality improvement efforts throughout 2019 and were adapted for online administration in 2020 for telerehabilitation patients. Outpatient visit counts by type (in-person, phone, and video) were extracted from the electronic medical record using data warehousing techniques. Results: Historical patient satisfaction rates from 2019 indicated high patient satisfaction (98.97% positive responses); these results were maintained for telerehabilitation visits (97.73%), indicating that families found telerehabilitation services acceptable. Patient volume returned to 73.5% of pre-pandemic volume after the implementation of telerehabilitation services." (Tanner, K., et al., 2020)      

The submitted documentation does not support the need for the requested services to be considered medically necessary for this patient.
A report of neuropsychological testing recommends applied behavioral analysis (ABA) for 10 hours/week. Needs-related services are required to address language and motor deficits identified and recommended speech/language therapy (SLT), occupational therapy (OT), and physical therapy (PT). An undated letter outlines goals and refers to an evaluation noting a need for more OT. A report from OT focused on handwriting. There is a report dated and a summary.
The insurer is correct that there were no objective, measurable findings, standardized test scores, or reassessment submitted compared to the initial findings to support the medical necessity.
For the dates in question, ongoing deficits could have been addressed via the use of a home program supervised by trained and non-medical individuals (family, caretakers). Therefore, given this and the lack of failure to respond to a home program, the services are not supported. 
                                               
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for therapeutic activities for multiple dates is not substantiated.