Hypotonia: 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.

Physician 1: The patient is a nine-year-old female who presents with various diagnoses including autism, post-traumatic encephalopathy, static encephalopathy and attention deficit disorder. She has also been diagnosed with verbal dyspraxia. The patient has been receiving occupational therapy including sensory integration therapy with some improvement. The Health Plan has denied authorization for continued occupational therapy on the basis it has not been shown to be efficacious for patients such as this patient.Autism is a complex, difficult disease. There are many treatment modalities, but few are universally accepted. Occupational treatment including a sensory integration component is a reasonable treatment approach for this patient’s diagnoses.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for one additional occupational therapy session per week (for a total of two sessions of occupational therapy per week).Findings: The physician reviewer found that records provided for review document that this patient has history of autism spectrum disorder and hypotonia. The patient has been making satisfactory progress in occupational therapy. There is insufficient evidence in the published literature to support that two sessions of occupational therapy per week are more beneficial for young patients with autism spectrum disorder than one occupational therapy session per week.

The parent of a 10-year-old female enrollee has requested an array CGH analysis for the treatment of the enrollee’s global developmental delay, hypotonia, macrocephaly, seizure disorder, hypermobility and mildly dysmorphic features. Findings: Three physician reviewers found that this patient has undergone an extensive and thorough evaluation in an attempt to put a name/diagnosis on her collection of symptoms. The proposed array CGH test is not likely to be clinically useful in this setting. There are no significant studies demonstrating it is beneficial in cases such as this, and there is only anecdotal information regarding the possible usefulness of the test.

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 hypotonia was denied, the published record says the denial is worth fighting.