Developmental Delay denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent requested authorization and coverage for a Rifton standing machine.Findings: The physician reviewer found that the enrollee has a diagnosis of hypotonia leading to significant developmental delay. He has been receiving outpatient physical therapy (PT) services with focus on improving overall functional mobility, strength, balance, and development of motor skills. In addition to PT services, he also receives occupational therapy (OT) and speech therapy (ST). He is currently utilizing bilateral supra-malleolar orthosis (SMOs), is non-ambulatory, has no independent mode of mobility, and is dependent for many activities of daily living and mobility skills. The enrollee has decreased muscle strength and low tone throughout his extremities and his trunk. He demonstrates rolling skills.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for genetic testing (cytogenomic SNP microarray). The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollee’s congenital cytomegalovirus and developmental delay. At issue in this case is whether the requested genetic testing (cytogenomic SNP microarray) is medically necessary for treatment of the patient’s medical condition.Per researchers, the clinical utility of chromosomal microarray (CMA) is well established. CMA is now considered first-line genetic testing for individuals with developmental delays and autism spectrum disorders. It is important to note that CMA technology has been shown to provide clinically actionable information.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent is requesting authorization and coverage for Applied Behavior Analysis (ABA) therapy. The patient is a nine-year-old male currently diagnosed with absent corpus callosum, Dandy-Walker malformation, developmental delay, epilepsy, and developmental speech and language disorder. Neurology evaluation indicates delayed milestones, with his receptive skill at around 80%. He displayed difficulty with non-verbal expressions, rigid thinking patterns, fixated interests and hyper/hyposensitive reactions to stimuli. The physician noted these were all characteristics of developmental delay and not autism spectrum disorder (ASD). However, the patient started applied behavior analysis (ABA) therapy. The record indicates he still did not meet ASD criteria, but had delayed social skills and repetitive behavior.

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 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 developmental delay, then check the rights and deadlines that apply to your plan.