Sensory Integration Therapy denials in California external review

What the reviewers wrote

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: An enrollee’s parent has requested reimbursement and prospective authorization and coverage for sensory integration therapy and authorization and coverage for functional activity. In a review of sensory integration therapy, researchers found moderate evidence to support the use of ASI within the scope of occupational therapy to improve performance. However, the authors noted that the results for sensory-based methods are mixed and further research with higher level studies with larger samples are recommended. The American Academy of Pediatrics (AAP) discussed the prescription of occupational therapy to children with delayed fine motor skills in guidelines.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient is a male child with an intermittent explosive disorder. Sensory integration therapies and occupational therapy services were requested. The Health Plan denied the request as not medically necessary.At issue, in this case, is whether the requested sensory integration therapies and occupational therapy are medically necessary for treatment of the patient’s intermittent explosive disorder.Sensory integration therapy is usually provided by occupational therapists. Various forms of sensory stimulation are provided to the patient, often in combination with purposeful muscle activities, with the goal of improving how the brain processes and organizes sensory information.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sensory integration therapy. There is insufficient evidence in current medical literature to support the use of sensory integration therapy in this clinical setting over any standard available therapy. In a systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders, Sharp and colleagues conclude, “Intensive, multidisciplinary treatment holds benefits for children with severe feeding difficulties.” Marshall and colleagues note that multidisciplinary intervention for childhood feeding difficulties may involve operant conditioning or systematic desensitization intervention, which help children improve in dietary variety/intake, and more reductions in difficult mealtime behaviors in children with autism spectrum disorder.

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