Pervasive Developmental Disorder: when insurers say no, reviewers often say yes

Where the denial was overturned

The patient is a 13-year-old male diagnosed with pervasive developmental disorder, depressive disorder and intermittent explosive disorder. He was treated emergently in October 2005 and held for acute psychiatric hospitalization due to gross violence against his mother. While at home, he became angry about what she was preparing for dinner and grabbed her by the throat and shoved her head against the kitchen cabinets. He had a prior history of violence inclusive of punching and biting his mother two weeks prior and an episode of choking her one-year prior when he was again upset about what she was preparing for dinner. The patient had also been admitted for inpatient psychiatric treatment four years prior due to behaviors that included charging at family members with a knife.

The parent of a four-year-old male enrollee has requested speech therapy for treatment of the enrollee’s non-specific pervasive developmental disorder with autistic features, or mild autism. Findings: The physician reviewer found that this patient has a definitive speech delay and a diagnosis of pervasive development disorder (PDD) based on testing by clinical psychologists. Of import, is that the speech pathologist based an assessment of speech development through a play session. The patient could not be tested by the Pre-Language Scale or the Goldman-Fristoe test, because of a lack of cooperation. In the clinical studies, it reports that children with speech delay can be readily treated, as confirmed in a review of multiple medical journal articles(Law and colleagues).

Where the denial was upheld

The parent of a 17-year-old male enrollee has requested residential treatment for the enrollee’s attention deficit hyperactivity disorder, anxiety disorder, not otherwise specified, and pervasive developmental disorder, not otherwise specified. Findings: The physician reviewer found that in this patient’s case, residential treatment was not indicated according to current evidence-based practice standards and expert consensus. The study by Wilmshurt involved random assignment of patients into two groups, one of which was treated in the community and the other of which received residential treatment. The residential group had worse outcomes on the whole than the group who remained in the community. In this particular case, the patient was described as cooperative throughout his stay.

The parent of a three-year-old male enrollee has requested applied behavioral analysis (ABA) therapy services for treatment of the enrollee’s receptive-expressive language disorder and pervasive developmental disorder. Findings: The physician reviewer found that the submitted documentation does not include conclusive testing establishing a diagnosis of autism spectrum disorder. Psychometric testing at age two years and four months noted a full-scale IQ of 106 and a later study at three years and eight months noted a full-scale IQ of 82 (low normal). Although autistic children can have normal full-scale IQs, especially those with Asperger’s syndrome, it is unusual for children diagnosed with pervasive developmental disorder – not otherwise specified (PDD-NOS) to have a normal IQ.

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 pervasive developmental disorder was denied, the published record says the denial is worth fighting.