Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prosptective authorization and coverage for speech therapy. Findings:  The physician reviewer found that The ability to communicate effectively with others is central to children's development. Delays or disruptions due to isolated expressive language delay, articulation errors, multiple sound production errors with motor planning deficits, or mixed expressive and receptive language delay, often bring widespread consequences. Capone Singleton reports that late talking children who do not receive professional intervention are placed at risk for life-long disability. OHare and Bremner emphasize the need for comprehensive speech and language assessment, along with speech therapy, for children with speech and language difficulty. Zwaigenbaum and colleagues review the importance of early intervention for children with autism spectrum disorder under three years of age, emphasizing that developmental and behavioral approaches often underlie the therapeutic strategies employed by speech and language pathologists. In a systemic review and evaluation of procedures for the induction of speech among persons with developmental disabilities, Mulhern and colleagues conclude that behavioral-based interventions were evidence-based to introduce speech to non-verbal individuals with developmental disabilities. Baumer and Spence report that for individuals with autism spectrum disorder, Treatment involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. Finally, the American Academy of Pediatrics states, Speech-language therapy is the most commonly identified intervention provided for children with autism spectrum disorder. The strategies used by speech-language pathologists to reinforce sound repetition and word use in children with typical development are often initially used with young children with autism spectrum disorder. Such strategies include reinforcement of speech sounds and communicative acts, imitation of the sounds the child makes, and exaggerated imitation and slowed tempo. The literature offers the most support for approaches with preverbal children with autism spectrum disorder in which adult prompts are used for communication, prompt fading, and reinforcement of their own attempts at communication. Intervention in naturalistic settings and involvement of caregivers may help reinforce the initiation of communication and functional use of sounds, gestures, and words. In this case, the patient has been evaluated by a speech-language pathologist. The records note severely impaired expressive language, oral placement, and articulation due to apraxia of speech. The patient has moderate impairment of social communication and pragmatic language as a result of her dual diagnosis of moderate-to-severe autism spectrum disorder. The records document baseline function, short-term and long-term therapy goals, and progress towards goals, and note that the patient and her parents have regularly attended therapy sessions. In this patients case, speech therapy was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, speech therapy was and is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special certification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.