Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is a male child with an intermittent explosive disorder. Sensory integration therapies and occupational therapy services were requested. The Health Plan denied the request as not medically necessary.At issue, in this case, is whether the requested sensory integration therapies and occupational therapy are medically necessary for treatment of the patients intermittent explosive disorder.Sensory integration therapy is usually provided by occupational therapists. Various forms of sensory stimulation are provided to the patient, often in combination with purposeful muscle activities, with the goal of improving how the brain processes and organizes sensory information. Sensory integration therapy has been a popular treatment for children with neurodevelopmental disorders (such as attention-deficit/hyperactivity disorder, autism and developmental delay) but there is significant controversy regarding its effectiveness. The American Academy of Pediatrics position statement on Sensory Integration Therapies for Children with Developmental and Behavioral Disorders, stated that parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive. In a review of sensory integration therapy, a study found moderate evidence to support the use of Ayres Sensory Integration within the scope of occupational therapy to improve performance. The results for sensory-based methods were mixed. Further research with higher level studies with larger samples was recommended. Another study noted that sensory integration therapy is a controversial treatment method that is widely used for people with disabilities. Systematic analysis of 17 single-case studies was conducted. The conclusion was that there was not convincing evidence for the effectiveness of sensory integration therapy and that its use should be limited to experimental contexts.More recently, a study performed a meta-analysis and systematic review of the literature on sensory integration therapy. The authors reviewed 11,436 abstracts between January 2007 and May 2015 and found only eight studies where the designs reflected high levels of evidence, and outcome measures addressed function or participation. The authors concluded that seven studies evaluated the effects of specific sensory techniques for children with autism spectrum disorder (ASD) or attention deficit hyperactivity disorder: massage, weighted vests, slow swinging, and incorporation of multisensory activities into preschool routines. The evidence is insufficient to draw conclusions regarding slow linear swinging and incorporation of multisensory activities into preschool settings. At present, there is insufficient evidence in the medical literature to support the use of sensory integration therapy. There is insufficient information regarding the need for occupational therapy. The requested sensory integration therapy and occupational therapy are not medically necessary for treatment of the patients behavioral health condition. 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 subspecialty certification in child neurology, 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.