Global Developmental Delay denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of a two-year-old male has requested authorization and coverage for a Bantam stander for the treatment of the enrollee who has been diagnosed with microcephaly and global developmental delay. Findings: 2/3 of the physician reviewers found that the requested equipment is likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. The device will enable the patient to assume a variety of functional positions and facilitate weight-bearing on his long bones. This is likely to decrease the risk of osteoporosis as well as decrease the risk of developing contractures of the hip, knees and ankles. There will also be a decreased risk of pressure sores. Appropriate positioning will aid the maintenance of normal gastrointestinal function.

Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for Manual Test XomeDxPlus Duo genetic testing. Previous guidelines from the American College of Medical Genetics and Genomics (ACMG) suggested that chromosomal microarray and fragile X syndrome testing should be first-tier tests for male patients with unexplained global developmental delay and/or autism spectrum disorder (Schaefer, et al.). Currently, exome sequencing is recommended as a first- or second-tier clinical diagnostic test for patients with neurodevelopmental disorders (Manickam, et al.). Exome sequencing outperforms chromosomal microarray, which has historically been the first-tier test for the evaluation of patients with neurodevelopmental disorders (Srivastava, et al.). This patient has been diagnosed with global developmental delay and autism spectrum disorder.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for direct 1:1 applied behavior analysis (ABA) therapy, to be provided at four hours a day for five days a week (total of 20 hours per week). Based on the presented medical information, the Council of Autism Service Providers (CASP) and ABA Coding Coalition ABA treatment guidelines, and the criteria by Papatola and Lustig, the requested direct 1:1 ABA therapy, to be provided at four hours a day for five days a week (total of 20 hours per week) is not medically necessary for treatment of this patient. The records document that this patient has several medical and developmental diagnoses that are impacting her ability to independently navigate her environment, and supports are needed. Per the ABA Coding Coalition, global developmental delay may be an indication for ABA services.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for licensed vocational nurse services 56 hours per week. Based on a review of the information provided and the medical literature, there is a lack of support for the requested licensed vocational nurse services, 56 hours per week, for the treatment of this patient. The records indicate that the patient does not have a tracheostomy, is not dependent upon a mechanical ventilator, and does not have an oxygen requirement. The patient is stable from a cardiorespiratory and neurologic standpoint and does not have a seizure 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 global developmental delay, then check the rights and deadlines that apply to your plan.