Intellectual Disability: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for a safety enclosure canopy for use with a cubby safety bed. As noted in the medical literature, hospital and customized hospital beds may be required for use in the homes of patients with mobility problems. Patients who require special positioning, the use of special attachments, or the need for elevation of the head of the bed may benefit from a hospital or customized hospital bed. In addition, patients with other risk factors, including patients with cognitive impairments or weakness, may require additional safety measures, such as specialized padding or an enclosed bed to prevent falls and entrapment. In this case, the patient has autism and intellectual disability.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gene testing. This patient’s provider has recommended whole exome sequencing to assist in this patient’s diagnosis and treatment given his history of autism, intellectual disability, syncope, hallucinations, and arachnoid cyst. Whole exome sequencing is a comprehensive test, which identifies changes in a patient’s DNA that are causative or related to their medical concerns. In contrast to current sequencing tests that analyze one gene or small groups of related genes, exome sequencing analyzes the exons or coding regions of over 20,000 genes. Neurodevelopmental disorders are often complex clinical scenarios attributed to single-gene mutations that may be detected through exome sequencing.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for inpatient psychiatric hospital program with a complete medication wash and a psychiatric evaluation. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.

Nature of Statutory Criteria/Case Summary: the parent of a 13-year-old female enrollee has requested authorization and coverage for neuro-processing disorder evaluation and health care services; auditory processing disorder evaluation and health care services; sensory processing disorder evaluation and health care services; primitive reflex vision disorder evaluation and health care services; and optometric vision therapy. Findings: The physician reviewer found that the patient has severe limitations in speech, which is limited to a few words, and intellect. Per the record, attempts to test the patient for auditory processing disorder could not be completed due to the patient's inability to follow rudimentary directions. The patient’s parent has requested multiple therapeutic tests and interventions to determine and improve the patient’s functional skills.

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