Diagnosis: Autism Spectrum Disorder

Treatment: Weekly therapy services

The insurer denied coverage for weekly therapy services.

The denial is overturned.

This case involves a patient who has been diagnosed with autism spectrum disorder. The documentation indicated he has poor fine motor skills as well as difficulty completing activities of daily living. He was recommended to participate in physical and occupational therapy sessions due to the above. The documentation indicated the patient was seen for additional therapy. The patient demonstrated impairments with handwriting as well as fine motor control imprecision in addition to emotional regulation. He struggles with anticipation of challenging tasks and regulation in reference to beginning these tasks. He also will become easily discouraged. The above impairments limit his ability to successfully participate in activities. It was recommended he continue to receive additional therapy services in order to maximize his independence in daily functional tasks. The documentation indicated he required moderate assistance in order to tie shoes. He requires verbal cueing to utilize strategies for regulation. He also had a short-term goal of successfully fastening a button. The documentation indicated he did improve and was able to successfully fasten the button 1 of 3 times on average. The patient also demonstrated great improvement with correct letter formation and has steadily been increasing in accuracy. He continued to require moderate to maximum verbal cues to identify at least 3 strategies for self-regulation. The recommendation was made for continued therapy services.

The provided documentation indicated the patient meets nationally recognized Centers for Medicare and Medicaid Services Criteria for Occupational Therapy Services. The patient has functional deficits in activities of daily living related to his autism spectrum disorder. The records included a plan of care for occupational therapy. Specifically, the occupational therapist is focusing on attention to task, independence in executing gross motor movements, independence with self-care skills, improving emotional regulation skills, and improving visual perceptual skills. The submitted records also include notes to show that the patient has made progress, but continues to have functional deficits and is working toward goals. Given the standard of care is to participate in therapy services to address ongoing deficits related to autism, ongoing services would be appropriate given prior benefit.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the weekly therapy services is substantiated. The insurer's denial is overturned.