Sensory Processing Disorder: 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 parent of a patient has requested authorization and coverage for sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one on-one) patient contact. This young patient has multiple difficulties modulating sensory information and responding in an age-appropriate manner to his environment and the usual demands of childhood. Recent literature has added to the growing body of information about the use of sensory integration techniques with children that have difficulties processing sensory information. Most of the literature involves children on the autistic spectrum, making it somewhat difficult to apply to the more general population. However, these articles do provide guidance in the application of the therapy techniques.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested sensory processing integration therapy for treatment of the enrollee’s autism and sensory processing disorder. Two physician reviewers found that the requested therapy is likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. Sensory processing disorder is described as an “overload” of receiving sensory perceptions which in-turn leads to an “over-response” of behaviors. The present concept is that an autistic patient’s abnormal behaviors stem from an “over-response” to environmental stimuli and treatment of his sensory processing disorder can only be treated by highly qualified and a specifically trained occupational therapist. Sensory integration therapy has a robust medical literature as to its long-term value.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the STAR program for treatment of the enrollee’s sensory processing disorder. Findings: Two physician reviewers found that the American Academy of Pediatrics (AAP) released a policy statement for sensory integration therapies for children with developmental and behavioral disorders. The AAP states that it is unclear whether children who present with sensory-based problems have an actual disorder of the sensory pathways or whether these deficits are associated with other developmental and behavioral disorders. The AAP notes that because there is no universally accepted framework for diagnosis, sensory processing disorder generally should not be diagnosed.

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent has requested authorization and coverage for occupational therapy using sensory integration therapy once a week and normal occupational therapy (OT) once per week. According to the enrollee’s medical record, this enrollee is diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and Sensory Processing Disorder. His parent reported that the enrollee was having behavioral issues at school such as over stimulation, mimicking other children and being troublesome and disruptive in class. Previously, he did fine in a smaller group of children and the issue had started when he was sent to a bigger group. He was fine when with his parents. The enrollee could not sit still in the classroom, but his father did not want to start him on medications.

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 sensory processing disorder was denied, the published record says the denial is worth fighting.