Develop Delay Cog: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The enrollee’s parent has requested authorization and reimbursement for pediatric day health care and private duty nursing/nursing care at home. The record indicates the enrollee is diagnosed with Koolen de Vries Syndrome after genetic testing was done and revealed KANLS1 mutation. The enrollee had been feeding poorly after delivery and magnetic resonance imaging (MRI) of the brain showed dysplastic corpus callosum. She spent approximately four weeks in the Neonatal Intensive Care Unit prior to discharge home, related to her feeding issues. She subsequently underwent gastrostomy tube placement and takes 40% of nutritional needs by mouth, with the rest being delivered via gastrostomy (G) tube. She has hypotonia, eustachian tube dysfunction, tracheomalacia, reflux, silent aspiration, audio neuropathy and developmental delay.

Nature of Statutory Criteria/Case Summary: The parents of an enrollee has requested reimbursement and prospective authorization and coverage for occupational therapy with sensory integration therapy services provided in the months of July and August of 2021 and forward.Findings: Two out of three medical experts decided that occupational therapy with sensory integration therapy services provided in the months of July and August of 2021, and forward were and are likely to be more beneficial for the enrollee than any available standard therapy.Children with sensory integration/modulation disorders (SID) present with delays or inability to meet expected milestones in different domains of development. Additionally, they have behavioral, sleep and psychological issues that are problematic in home and school settings.

Where the denial was 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 patient’s 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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sensory integration therapy. There is insufficient evidence in current medical literature to support the use of sensory integration therapy in this clinical setting over any standard available therapy. In a systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders, Sharp and colleagues conclude, “Intensive, multidisciplinary treatment holds benefits for children with severe feeding difficulties.” Marshall and colleagues note that multidisciplinary intervention for childhood feeding difficulties may involve operant conditioning or systematic desensitization intervention, which help children improve in dietary variety/intake, and more reductions in difficult mealtime behaviors in children with autism spectrum disorder.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for develop delay cog was denied, the published record says the denial is worth fighting.