Social Skills Thpy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested group speech therapy services and social skills for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. Group speech therapy services and social skills are indicated to address the social skills deficits with the patient’s peers. The patient presents with good expressive and receptive language skills. However, standardized tests do not pick up the problems with social communication that is seen in a child with autism spectrum disorder. According to the American Academy of Pediatrics “People with ASDs have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested group social skills therapy for treatment of the enrollee’s autism spectrum disorder. Findings: The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. There is evidence that social skills groups are effective for children with autism spectrum disorders (ASD) to improve social skills and friendship quality. However, most of the peer-reviewed literature in regards to social skills groups does not include children who are also receiving applied behavior analysis (ABA). Social skills groups are designed to refine communication and work on conversational reciprocity and staying on conversational target.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested group social skills therapy for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that social skills groups are indicated for children with autism spectrum disorders. However social skills groups are primarily indicated for school age children who are not receiving applied behavior analysis (ABA) services. The primary goals of the social skills groups are social competence, social communication and emotion recognition. In this case, parental concerns include non-compliance, repetitive behaviors, disruptive and aggressive outburst behaviors and public behavior. The requested intervention is not designed to address aggression and non-compliance.

Nature of Statutory Criteria/Case Summary: The parent of a four-year-old male enrollee has requested reimbursement and prospective authorization and coverage for social skills group therapy and group speech therapy services. Findings: The physician reviewer found that based on the available documentation, the social skills group therapy and group speech therapy services provided were not and are not medically necessary for treatment of this patient’s medical condition. The National Autism Center highlights ABA therapy as the most effective evidence-based treatment for autism. In this case, the patient is currently accessing medically necessary treatment in the form of ABA therapy, which has led to a decrease in overall autism symptoms. While the patient still has specific areas of concern, his ABA provider has outlined goals to focus on the patient’s specific deficits.

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 Social Skills Thpy, then check the rights and deadlines that apply to your plan.