Sensory Integration Occupational Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

The parent of a five-year-old male enrollee has requested social cognitive speech therapy and sensory integration occupational therapy for the treatment of the enrollee’s autism. Findings: The physician reviewer found that the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) considers occupational and speech therapies to have medical value in patients who qualify based on ICF’s definition of health, function and disability. While school therapies will often focus on socialization, communication, social interaction, and pragmatics, there are many aspects of pragmatic, expressive and receptive language that will not be taught by the school programs.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested occupational therapy and sensory integration occupational therapy for treatment of the enrollee’s autism spectrum disorder. The physician reviewer found that in this case, traditional OT is not medically necessary as the patient’s fine motor skills are in the average range. However, sensory integration OT is medically necessary for treatment of the patient’s medical condition. According to the American Academy of Pediatrics “Traditional occupational therapy often is provided to promote development of self-care skills (eg, dressing, manipulating fasteners, using utensils, personal hygiene) and academic skills (eg, cutting with scissors, writing).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sensory integration occupational therapy. Sensory integration occupational therapy is not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. Various forms of sensory stimulation are often combined with purposeful muscle activities, with the goal of improving how the brain process and organizes sensory information. Sensory integration therapy has been a popular treatment for children with neurodevelopmental disorders such as autism and developmental delay but there is significant controversy regarding its effectiveness. In the medical literature, researchers noted that sensory integration therapy remains a controversial treatment method supported by limited scientific data.

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested authorization and coverage for sensory integration occupational therapy. Findings: The physician reviewer found that there is significant controversy in the peer-reviewed literature regarding the effectiveness of sensory integration occupational therapy. The authors found that the methodology of the studies was poor. Most of the studies used weak designs, with a tendency for higher quality studies to produce negative results. Based on limited comparative evidence, functional analysis-based interventions for challenging behavior, such as applied behavioral analysis (ABA) therapy, were more effective than sensory integration therapy. Overall, the studies do not provide convincing evidence for the efficacy of sensory integration therapy.

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 Occupational Therapy, then check the rights and deadlines that apply to your plan.