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 one additional occupational therapy session per week (for a total of two sessions of occupational therapy per week).Findings:  The physician reviewer found that records provided for review document that this patient has history of autism spectrum disorder and hypotonia. The patient has been making satisfactory progress in occupational therapy. There is insufficient evidence in the published literature to support that two sessions of occupational therapy per week are more beneficial for young patients with autism spectrum disorder than one occupational therapy session per week. The guideline report on the treatment of autism spectrum disorder published by the American Academy of Pediatrics (AAP) describes that, Children with autism spectrum disorder may have low muscle tone or a developmental coordination disorder. Although the ages for sitting and walking do not differ between children with autism spectrum disorder and children with typical development, both fine and gross motor skills may be delayed in preschool-aged children with autism spectrum disorder. Occupational therapy services may be indicated to promote fine motor and adaptive skills including self-care, toy use, and handwriting (Hyman, et al.). Monz and colleagues noted that, The American Academy of Child and Adolescent Psychiatry recommends the use of multiple treatment modalities in autism spectrum disorder. Although occupational therapy is generally accepted to be medically necessary in the treatment of autism spectrum disorder, data are lacking in the published literature to support optimal intensity and dosage of occupational therapy for children. Gee and colleagues performed a meta-analysis and concluded that, evidence is lacking within the published literature to adequately guide occupational therapy dosage decisions. At present, there is insufficient evidence to support that two sessions of occupational therapy per week are medically necessary for the patient in lieu of one session per week. The patient would likely continue to make progress with one occupational therapy session per week. There is insufficient evidence in the published literature demonstrating an optimal number of OT therapy sessions, and that two sessions per week are of any greater benefit. Moreover, the requested one additional occupational therapy session per week (for a total of two sessions of occupational therapy per week) is not medically necessary to prevent disease, disability, and other health conditions or their progression; or to correct or ameliorate any physical or behavioral conditions. Therefore, the requested one additional occupational therapy session per week (for a total of two sessions of occupational therapy per week) is not medically necessary for 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 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.