Asperger's Syndrome denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 15-year-old female who has been diagnosed with Asperger’s syndrome with obsessive behavior, hair pulling, and skin picking. The patient has been tried on multiple modalities including biofeedback vision therapy, occupational therapy, and tutoring with poor results. The patient was then placed in a multidisciplinary day program, which resulted in significant benefit. It has been recommended the patient continue to receive day treatment therapy. The Health Plan has denied authorization for the requested therapy indicating it is not medically necessary.Review of the reports of the individual therapies associated with the patient’s day treatment program reflect a well-coordinated effort to address the outlined goals. The measured goals are attainable and realistic.

The parent of a 10-year-old male enrollee has requested group occupational therapy, once per week for treatment of the enrollee’s Asperger’s disorder. Findings: The physician reviewer found that this patient has been diagnosed with Asperger’s syndrome, an autism spectrum disorder (ASD). The standard of care adopted by the medical community as set forth by evidence based guidelines for treatment of patients with ASD by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) recommends occupational therapy in this setting. Specifically, the organizations stated that, “immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach.” The literature reveals that the prevalence of impairments in fine and gross motor skills appears to be relatively high in autistic patients.

Where the denial was upheld

The patient is a 10-year-old male with the diagnosis of Asperger’s syndrome. He currently attends a special school and has attended a camp and group sessions to improve his socialization over the last two years. A review of the notes from the peer-involved group therapy demonstrates initial progress and improvement in most of the target areas with an apparent plateau. The parents request that the Health Plan provide coverage for this group socialization program, but the request has been denied on the basis that the therapy is not directed toward acute mental health issues and is not medically necessary.Though a review of the literature suggests that socialization with behavioral modification can be helpful in Asperger’s syndrome, in this case the patient has been receiving peer-involved group therapy for several years and seems to have reached a plateau.

The patient is a 16-year-old male with Asperger’s syndrome. His parents are requesting laboratory testing in conjunction with the Buttar Autism Treatment Protocol. The record does not include evidence of acute changes in the patient’s clinical condition or laboratory data suggestive of mercury exposure from vaccines or other sources. The Health Plan previously authorized screening tests for thyroid, iron, magnesium, mercury, lead etc. but apparently the laboratory work was not performed. The parent’s request for authorization of the laboratory testing included in the Buttar Autism Treatment Protocol was denied by the Health Plan based upon their determination that it is not medically necessary.A review of the scientific literature revealed no articles related to mercury and autism published by the proponents of the autism treatment protocol at issue and the related testing.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving asperger's syndrome, then check the rights and deadlines that apply to your plan.