Sensory Integration denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parents of an enrollee has requested reimbursement and prospective authorization and coverage for occupational therapy with sensory integration therapy services provided in the months of July and August of 2021 and forward.Findings: Two out of three medical experts decided that occupational therapy with sensory integration therapy services provided in the months of July and August of 2021, and forward were and are likely to be more beneficial for the enrollee than any available standard therapy.Children with sensory integration/modulation disorders (SID) present with delays or inability to meet expected milestones in different domains of development. Additionally, they have behavioral, sleep and psychological issues that are problematic in home and school settings.

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.

Where the denial was upheld

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.

Findings: The physician reviewer found that the patient’s parent has requested authorization and coverage for Central Auditory Processing Disorder Therapy (CAPDOTS)-Integrated (adolescent version) listening program and/or Safe and Sound Protocol hearing therapies. The submitted documentation does not support the medical necessity of the requested services. The records indicate that the patient has been diagnosed with autism spectrum disorder (ASD) and has a history of auditory processing disorder, attention deficit hyperactivity disorder (ADHD), combined presentation, bilateral hyperacusis, tinnitus, misophonia, and visual processing disorder. The records show that the patient underwent an auditory processing evaluation, which found that the patient’s hearing sensitivity for pure tones was in the normal range in both ears, with many thresholds below 0-decibel hearing level (dBHL).

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 Sensory Integration, then check the rights and deadlines that apply to your plan.