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

The enrollees parent is requesting authorization and coverage for speech therapy. The enrollee has autism spectrum disorder and presents with severe-profound, receptive-expressive language delay. His speech evaluation indicates the enrollees listening comprehension was at an age equivalent of two years eight months; oral expression was two years six months; receptive language was 17 months; expressive language was 24 months; and total communication was 22 months. According to the records, speech production was not tested due to limited expressive language ability and showed the enrollees oral structures and function appear to be within functional limits. The evaluator indicated the enrollee does not qualify for continued speech therapy. The child is receiving services in school. The family was provided education to facilitate speech and language development in the home. This enrollee has a diagnosis of autism spectrum disorder and mixed receptive/expressive language disorder. He underwent a speech and language re-evaluation with a private speech-language pathologist. On the Receptive-Expressive Emergent Language Test, third edition, the enrollees scores showed receptive language less than 55; age equivalent 8 months, expressive language less than 55; age equivalent 7 months, and language ability of 46. On the Preschool Language Scale, Fifth Edition, the enrollees scores were auditory comprehension 50; age equivalent 7 months, expressive communication 50; age equivalent 13 months, and total language not reported. On the Oral and Written Language Scales, Second Edition (OWLS-II), the composite scores were listening comprehension 40; age equivalent 2 years 8 months, oral expression 40; age equivalent 2 years 6 months, and oral composite 40. The medical literature cites criteria under which continued speech therapy for delay or disorders of speech and language is medically necessary. These criteria include the enrollee being at or under the age of twelve, the enrollee demonstrates objective, measurable progress during initial therapy, the enrollee shows a good response to interventions but continues to perform below average. The medical literature indicates most children with autism spectrum disorder will benefit from therapies designed to improve their ability to communicate and engage in social interactions. Research has shown that early intervention, focused on communication and social skills, can improve the outlook for these individuals. Therefore, school or academic settings are appropriate settings for social and further speech development. The enrollee has had over five years of speech therapy, with a noted plateau in gains regarding expressive language. There is no medical indication for speech therapy at this time.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in developmental-behavioral pediatrics 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 similar medical condition.