Occupational Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that The patient has requested authorization and coverage for full day speech, physical, and occupational therapies performed for up to four hours per day, five days per week. Current medical literature supports the use of rehabilitation in the context of traumatic brain injury (TBI). Researchers conclude regarding the effects of physical therapy interventions on balance impairments in individuals with TBI, “The evidence about the effects of the physical therapy interventions in improving the balance ability post-TBI was limited.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for (1) speech therapy services: one hour five times a week and (2) occupational therapy services: two hours three times a week. The submitted documentation supports the medical necessity of a portion of the requested services. The American Academy of Pediatrics guidelines on the identification, evaluation, and management of children with autism spectrum disorder (ASD) describes delayed language as an early concern for many children who are later diagnosed with ASD, and that the communication symptoms included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for ASD reflect core deficits in social communication and interaction including failure of back-and-forth communication, deficits in nonverbal communication such as eye gaze and use of g…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for (1) comprehensive assessment incorporating multiple settings (e.g., home, school) by a board certified behavior analyst (BCBA), (2) cognitive behavior therapy for 60 minutes per session once a week for eight weeks, and (3) occupational therapy for one weekly 60 minute session, for 12 weeks. The submitted documentation does not support the medical necessity of the requested services. In this case, the patient’s parent reports diagnoses of autism, attention deficit hyperactivity disorder (ADHD), and anxiety. However, the submitted records only documented a diagnosis of ADHD, apart from notes indicating that the patient’s mother reported that the patient had the possibility of an autism diagnosis following a second opinion.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for daily 1:1 therapies, to include: (1) occupational therapy 2x/week, (2) art therapy 1x/week, and (3) movement therapy 1x/week, in addition to the approved play 2x/week, eye movement desensitization and reprocessing (EMDR) 1x/week, and family therapy 1x/week. Findings: The physician reviewer found that At issue in this case is whether the daily 1:1 therapies, to include: (1) occupational therapy 2x/week, (2) art therapy 1x/week, and (3) movement therapy 1x/week, in addition to the approved play 2x/week, EMDR 1x/week, and family therapy 1x/week are medically necessary to treat the patient’s medical condition as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Occupational Therapy, then check the rights and deadlines that apply to your plan.