Diagnosis: Autism

Treatment: medical equipment, E1399 x 6, special enclosed cubby bed

The insurer denied coverage for medical equipment, E1399 x 6, special enclosed cubby bed
The denial is overturned

The patient is a female with autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD). She receives physical, occupational and speech therapy services at school. Under review is the medical necessity of requested medical equipment, E1399 x 6, special enclosed cubby bed.

The insurer denied the request for medical equipment, E1399 x 6, special enclosed cubby bed, citing "no indication that standard covered medical supplies failed to meet the patient's needs. There is no indication that less intensive alternatives to improve the patient's safety have been tried. These include bed rails, mattress on the floor, removal of all safety hazards, bed alarms, and video/audio monitors." However, in a letter, the patient's mother discusses several fewer intensive alternatives to improve the patient's safety that have been tried without success, including toddler bed, bed rails, audio/visual monitoring as well as other strategies such as child proofing home and other features (e.g., white noise machine, night lights, bed/door alarms, doorway gates). Given the failure of the other less intensive alternatives, the requested special enclosed cubby bed, is a reasonable safety measure and should be considered medically necessary.

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

The insurer's denial of coverage for the medical equipment, E1399 x 6, special enclosed cubby bed, is overturned. Medical Necessity is substantiated.