Perv Devlop Disorder: when insurers say no, reviewers often say yes

Where the denial was overturned

The parent of a six-year-old male has requested occupational therapy services for treatment of the enrollee’s pervasive developmental disorder. Findings: The physician reviewer found that autism spectrum disorder (ASD), of which pervasive developmental delay (PDD) is one manifestation, is a complex neurological disorder with characteristic deficits in speech/language and social interaction. There are likely a multitude of etiologies, with clinical symptoms being the common denominator. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in children with ASD. Typically, young patients on the autistic spectrum require interventions in multiple areas, provided using a team approach.Praxis is the process of organization that involves ideation, motor planning, and execution of a purposeful action.

The parent of a six-year-old female enrollee has requested coverage for speech therapy services for treatment of the enrollee’s pervasive developmental disorder. Findings: The physician reviewer found that autism and the related pervasive developmental disorders are characterized by patterns of delay and deviance in the development of social, communicative and cognitive skills which arise in the first years of life. Early, sustained intervention is indicated, as is the use of various treatment modalities, including speech-communication therapy and behavior modification. While there have been few studies offering a direct comparison of methods, it is the prevailing opinion among specialists in the field that children with autism benefit from intensive, early intervention methods which focus on increasing the frequency, form and function of communicative acts.

Where the denial was upheld

The parent of a 6-year-old male has requested applied behavioral analysis (ABA) therapy for treatment of his pervasive developmental disorder - not otherwise specified (PDD-NOS), oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD). Findings: The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments.

The parent of a 16-year-old male enrollee has residential treatment center services for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that the submitted documentation fails to establish the medical necessity of the residential treatment center services. The medical records indicate that on the specified date, the patient had an improved affect. He was not suicidal, homicidal or psychotic, and he retained linear thought processing. The medical records also indicate that the patient was active in treatment. His episodic thoughts of suicide had resolved. He had no behavioral problems in the program. The patient did have anticipatory anxiety as discharge approached, fearing that upon discharge he would resume feuding with his parent. However, the patient’s treatment plan and medication regimen was not modified due to this concern.

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 perv devlop disorder was denied, the published record says the denial is worth fighting.