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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for three 30-minute speech therapy sessions weekly, a single one-hour physical therapy session weekly, and a single one-hour occupational therapy session weekly. The records document that this patient has been diagnosed with autism spectrum disorder, mixed receptive-expressive language disorder, and developmental coordination disorder. The patient has a mutation in the JMJD1C gene, which has been described as being associated with autism spectrum disorder and developmental delay. The patients receptive, expressive, and pragmatic language skills are severely delayed. In addition, the patient has a 50% delay in his fine motor skills. The provider has recommended treatment with applied behavior analysis (ABA), occupational, physical, and speech therapies. In recent guidelines, the American Academy of Pediatrics (AAP) supports the provision of speech, occupational, and physical therapies for young patients with autism spectrum disorder (ASD) (Hyman, et al.). With regard to speech therapy, the authors commented that, All children with ASD should have documentation of specific coexisting speech and language diagnoses so that appropriate intervention might be provided. Regarding occupational and physical therapy, Hyman and colleagues described that, Although the ages for sitting and walking do not differ between children with ASD and children with typical development, both fine and gross motor skills may be delayed in preschool-aged children with ASD. The authors found that, Occupational therapy services may be indicated to promote fine motor and adaptive skills, including self-care, toy use, and handwriting. Bilaver and colleagues noted that almost two-thirds of preschool-aged children with ASD are reported to receive occupational therapy services. This patient has been described as having developmental coordination disorder and he toe-walks. Hyman and colleagues discussed the need for physical therapy in some young patients with ASD, stating that, Toe walking is common among children with ASD as well as in other developmental disorders in early childhood. In this clinical setting, the patient meets the criteria for treatment with speech, occupational, and physical therapies. Moreover, the requested three 30-minute speech therapy sessions weekly, a single one-hour physical therapy session weekly, and a single one-hour occupational therapy session weekly are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and are not primarily for the convenience of the patient or provider. Therefore, the requested three 30-minute speech therapy sessions weekly, a single one-hour physical therapy session weekly, and a single one-hour occupational therapy session weekly are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology with expertise in neurodevelopmental disabilities 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.