Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 55-year-old man with left temporal lobe necrosis due to radiation therapy.  He has left facial dysarthria and impairments in language, memory and information processing.  He is not able to work due to his disabilities, but would like to resume his previous employment.  The patients treating physician referred him for speech therapy, which was denied by the Health Plan based upon their determination that speech therapy is investigational in this clinical context. The goals of speech therapy are to train compensatory strategies for memory and word achievement.  These are appropriate goals, and likely to be beneficial to the patient.  Speech therapy would be particularly more beneficial than the alternative of no treatment. Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 55-year-old man with a squamous cell carcinoma at the base of the skull and secondary radiation necrosis.  He has mild aphasia and cognitive difficulties as a result of the necrosis and residual speech problems related to damage to cranial nerves VII through X from a prior surgery.  The patient has been evaluated for speech therapy and appears to be a good candidate.  He is requesting authorization for 16 sessions of speech therapy over an eight-week period.  The Health Plan has denied the request based upon their determination that speech therapy is an investigational intervention for treatment of the patients speech and language deficits.Speech therapists are trained to assist patients with speech, language, and cognitive deficits and to enable them to improve their functional abilities in these areas.  The requested speech therapy services are reasonable for a patient with aphasia and dysarthria. Speech therapy two times per week is a reasonable treatment approach and is likely to be more helpful to this patient than any other treatment modality.  Based upon the information set forth above, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: The patient is a 55-year-old male who received radiation therapy for skull base squamous cell carcinoma. He now has mixed aphasia due to radiation necrosis in the left hemisphere.  The patient and his provider are requesting speech therapy to help with his speech, language and cognitive difficulties.  The Health Plan has denied this request on the basis that speech therapy is considered investigational for treatment of mixed aphasia due to radiation necrosis.Speech therapy for treatment of mixed aphasia secondary to left hemisphere pathology is consistent with the generally accepted standard of care. The requested therapy is not an experimental or investigational modality and should be available to this patient. It is likely the patient will experience greater benefit from the requested therapy than from any other treatment (or no treatment). Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.