Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism spectrum disorder and global developmental delay
 
Treatment: therapeutic procedures (aquatic therapy) procedure code 97113 for 20 visits 

The insurer denied coverage for therapeutic procedures (aquatic therapy) procedure code 97113 for 20 visits. The denial is upheld. 

This patient is a male child currently diagnosed with autism spectrum disorder and global developmental delay.  The patient's past medical history was significant for gastroesophageal reflux and frequent ear infections.  The patient underwent bilateral myringotomy tube placement. A letter of appeal indicates that the patient is receiving physical therapy (PT) and occupational therapy (OT) at school. No details are provided. A letter indicates that the patient has been approved for special instruction and OT as part of the Early Intervention Program (EIP).  There are no current records provided indicating the extent of the PT/OT given to the patient, the results of the PT/OT services provided, goals etc.  Aside from the above letters/notes, no clinical data is provided for review.  Please note that a request for documentation was sent for all medical records and for any information relevant to the issue at hand. Aquatic therapy was recommended as a medically necessary therapy to address the patient's significant deficits in motor coordination and sensory processing abilities.  

The insurer states that this case was previously denied as the medical notes indicated that the patient had problems with coordination and balance.  However, the medical notes did not show why the patient needed to have therapy at the office or if the goals were different from the school the child attended.  It was further noted that there should be a clear reason on how the therapy goals are different from the ones given at school.  The medical notes must have separate evaluations and goals that are different from school.  They state that the school plan of care was not included for the review.

Current literature and standards of care recommend treating infants and young children with developmental delays as soon as possible.  Treatments such as physical therapy, occupational therapy, and speech therapy help prevent worsening of the condition or improve the condition over time.  Physical therapy and occupational therapy can be land based or performed in a therapeutic pool. Therapy interventions with a task-orientated framework can improve gross motor outcomes in children with developmental delays and autism.  Aquatic therapy improves motor skills of persons with Autism Spectrum Disorders (ASD) and can be useful for ameliorating functional impairments of children with developmental delays caused by ASD.
  
Based on the current literature, while aquatic therapy has a role in treating patients with autism, the lack of supporting clinical records and the fact that the patient was being provided with physical therapy at school, does not support the medical necessity for the therapeutic procedures (aquatic therapy) procedure code 97113 for 20 visits. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The therapeutic procedures (aquatic therapy) procedure code 97113 for 20 visits is considered not medically necessary for this patient.

The carrier's denial of coverage for the therapeutic procedures (aquatic therapy) procedure code 97113 for 20 visits is upheld.  The medical necessity is not substantiated.