(1) medically necessary services (b)

Transcription

1 The Wisconsin Occupational Therapy Association is requesting to have Sensory Integration Therapy taken out of the TIAC review process because it does not fit the criteria of being a nonmedical intervention. We also want to bring concerns about the process of the Bureau of Long Term Care and the Treatment Intervention Advisory Committee (TIAC) reviewing the research compiled on non-medical treatments to the Department of Health Services, BLTC and TIAC. We asked for reconsideration of the rating of Sensory Integration Therapy as a level 4 at the January 2014 meeting of the TIAC, though we are providing the reasons why SIT should not have been included as a technique even reviewed by the TIAC. 1. WOTA raises the issue that Sensory Integration Therapy should not have been required to undergo the review by the TIAC because Sensory Integration is already listed in the Medicaid CPT codes as medically necessary and has been reimbursed by the Medicaid program for several years as such. The TIAC committee is to review nonmedical interventions. The following is excerpted from the Medicaid Code. DHS Note (e) Sensory integrative evaluation and training which, because of the type of training or the condition of the patient, must be performed by or under the supervision of a qualified occupational therapist or physical therapist or other appropriate licensed health care provider to ensure the safety of the patient and the effectiveness of the treatment; DHS (1) (1) Covered services. Covered occupational therapy services are the following medically necessary services when prescribed by a physician DHS (1)(b) (b) Sensory integrative skills, as follows: DHS (1)(b)1. 1. Reflex/sensory status; DHS (1)(b)2. 2. Body concept; DHS (1)(b)3. 3. Visual-spatial relationships; DHS (1)(b)4. 4. Posture and body integration; and DHS (1)(b)5. 5. Sensorimotor integration; 2. Occupational Therapy services (inclusive of SIT-Sensory Integration Therapy) are included in the Autism Insurance Mandate and there is a requirement for evidenced based practice to be included in the mandate. 3. Occupational Therapy practitioners are qualified health care providers. They have graduated from accredited programs in Universities and Colleges. They are required to complete clinical internships, take a national certification exam, and are required to be licensed/regulated in every state. OT services are provided in a broad range of sites, Hospitals, Skilled Nursing Facilities, Mental Health settings, homes, schools and the community. The providers of many of the techniques that have been reviewed by the TIAC do not meet the level of preparation that Occupational Therapy practitioners are required to have to practice OT. Many of the other techniques used in level 1 or 3 rated researches do not have the potential 1

2 to cause harm that Sensory Integration programs have because SIT techniques can impact the central nervous and have to be conducted by trained individuals who have medical background and should not be done by people who are not trained as OTs. 4. The TIAC criteria used to determine the level of evidence for specific therapies rely on: 1) Findings of consensus reports 2) Quality, quantity, and outcomes of studies published in peer-reviewed journals 3) Replicability of the treatment 4) Confirmation of participants ASD diagnosis The TIAC published five levels of criteria they would use to assess the interventions with, the five levels are included here: AOTA used the above published criteria to select and submit evidence that validated the efficacy of Sensory Integration Therapy that met the criteria at a level 2 of the five levels of evidence. Based on the extant research literature and relative to the criteria used by the DLTC- TIAC, SIT has unequivocally achieved a Level 2 rating (Level 2 Established or Moderate Evidence) and is therefore a proven and effective treatment for individuals with autism spectrum disorders and/or other developmental disabilities. It is NOT an experimental treatment. (taken from testimony provided by Dr Florence Clark PhD, OTR/L, FAOTA at the July 26, 2013 TIAC meeting) 2

3 AOTA and WOTA were able to offer research that met each one of the TIAC published criteria included here with the following attachments. AOTA letter to the BLTC/TIAC - Sensory Integration Research Testimony Florence Clark. Dr. Clark has an Ed.D in Educational Psychology and a PhD in Occupational Science. She has received numerous grants from the NIH National Institute of Health so is very well versed in research. She obtained the criteria that TIAC would use to determine if SIT research met the standards required. Dr. Clark used the resources of Southern California University s research department to conduct the review. She also was appointed to a similar committee to TIAC in California and was conducting reviews on techniques used for children with autism. 5. One of the comments made by Dr. Bass as one of the reviewers of SIT was that the techniques were conducted by the creator/provider of the treatment and not an independent researcher. Studies are being done by therapists who believe in the techniques and are using it in practice, not by impartial, independent researchers. and the studies were not conducted by someone other than the creator /provider of treatment. (Roger Bass in the report to the TIAC committee on Nov. 22, 2013) We would challenge this statement as it relates to SIT because the original creator was A. Jean Ayres in None of the studies submitted were conducted by Dr. Ayres. Also SIT techniques have the capacity to affect the central nervous system and as such should be conducted by knowledgeable skilled Occupational Therapists and Occupational Therapy Assistants not just anyone without an extensive medical background. 6. It appears that the committee based their determination that SI evidence was at a Level 4 Insufficient Evidence both on the published 5 levels and also on the "unpublished criteria" included in the Research Review spreadsheet developed by Dr. Roger Bass. We would assert that the same criteria (Research Review sheet with approx. 160 variables) was not used in every one of the reviews the committee completed and it was not published in advance so that every technique being reviewed would know how the research was assessed. If this is the case Sensory Integration Therapy was assessed at a higher level of scrutiny than the first techniques reviewed. The first group of interventions that were reviewed by the committee were these five and it was decided at the 4/9/2012 meeting that Committee members will review the following proposed treatments: Applied Behavior Analysis Brain Balance Hippotherapy Music Therapy The Play Project At this meeting the TIAC agreed to: (taken from the Committee minutes of 4/9/2012) 3

4 Committee members then reviewed the following proposed treatments: 4/9/2012 Rapid Prompting Method Multisystemic Therapy The Early Start Denver Model SCERTS Techniques reviewed on November 22, 2013 DIR/Floortime Equine-Assisted Psychotherapy SCERTS Model (social communication, emotional regulation, transactional support) Sensory Integration Therapy TEACCH model Tomatis Therapy Updates Music Therapy Relationship Development Intervention WOTA has not been able to determine by reading Committee minutes when it was decided to use an additional set of criteria to evaluate the research. We have been unable to find any place that the Research Review Spreadsheet that Dr. Roger Bass developed was being used in addition to the published criteria. Dr. Bass sent this spreadsheet by to Teri Black WOTA President, when she requested at the November 22, 2013 TIAC meeting. 7. In the CMCS Informational Bulletin July 7, 2014 that was provided by the Center for Medicare and Medicaid the following section related to therapy services was included. There was also a FAQ section issued by CMS that stated: Additionally, any medically necessary services for ASD should not be denied or delayed while these reviews take place. I have included those excerpts here. Wisconsin is already well advanced in implementing coverage for ASD services by having established the TIAC to conduct the reviews of many non- medical interventions. This excellent process could be used by other states as a model to determine coverage under their Medicaid programs. Wisconsin will need to be reviewing their policies related to these CMS memos. DATE: July 7, 2014 FROM: Cindy Mann, Director Center for Medicaid and CHIP Services SUBJECT: Clarification of Medicaid Coverage of Services to Children with Autism file:///c:/users/guestuser/downloads/clarification%20of%20medicaid%20coverage %20of%20Services%20to%20Children%20with%20Autism%20%2528CMS%20- % %2529%20(1).pdf 4

5 Therapy Services Physical therapy, occupational therapy and services for individuals with speech, hearing and language disorders, may be covered under the Medicaid therapies benefit at 42 CFR Physical and occupational therapy must be prescribed by a physician or other licensed practitioner of the healing arts within the scope of his/her practice under state law and provided to a beneficiary by or under the direction of a qualified therapist. CMS Issues FAQ on ASD Guidance Last week, the Centers for Medicare and Medicaid Services (CMS) issued a set of Frequently Asked Questions (FAQ) regarding its guidance issued last July on the coverage of Autism Spectrum Disorder (ASD) services as a Medicaid benefit under EPSDT. The FAQ addresses five aspects of the ASD guidance. They are: 1. The ASD guidance does not mandate states to cover Applied Behavioral Analysis (ABA) therapy in their Medicaid programs. ABA therapy is one ASD treatment modality, but states may determine what ASD services are medically necessary, which may or may not include ABA. CMS does not endorse any particular treatment modality. 2. CMS has no specific timeframe for when it will conduct review of state policies in this area, though the July guidance was effective immediately. CMS understands that states may need time to evaluate their programs and policies relating to ASD, and encourages states to do so in consultation with their stakeholder communities without delay. Additionally, any medically necessary services for ASD should not be denied or delayed while these reviews take place. Technical assistance is available from CMS for interested states to sort through these issues. WOTA believes that we have presented many relevant points that reinforce our request of the BLTC and TIAC to have Sensory Integration Therapy taken out of the TIAC review process because it does not fit the criteria of being a non-medical intervention and does meet the criteria of being a medically necessary service. WOTA is very willing to work with the Department of Health Services, Medicaid and the Bureau of Long Term Care, as they look at implementing the CMS guidelines. WOTA Legislative Chair Teri Black COTA ROH black@madisoncollege.edu