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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement and authorization and coverage for speech therapy services, 50 minutes one time per week. The enrollee has a diagnosis of autism, with speech and social delays.  A neuropsychological evaluation showed her verbal abilities were weaker than her nonverbal and visual spatial skills, but not at a statistically significant level.  Oral language skills, listening comprehension and math fell below the average range.  Weaknesses were exhibited in her receptive language skills, and she had difficulty sustaining her attention and inhibiting impulsive behavior. She was at the seventh percentile in vocabulary skills.  She underwent a neuropsychological re-evaluation. Listening comprehension, receptive vocabulary and repetition of sentences now ranged from average to high average.  She demonstrated the most progress in the area of speech and language; however, pragmatic language was still an area of weakness.  The neuropsychological re-evaluation noted that the enrollee had made improvements in academic skills, language and behavior.  The enrollees speech therapist reports the enrollee has moved from being unable to hold a conversation to engaging in reciprocal interactions. Children on the autistic spectrum require interventions in multiple areas; including speech therapy. Deficits in communication are integral to the diagnosis of autism and are the foundation for many of the clinical findings.  The sooner and more aggressively these deficits are targeted, the better chance the child has for developing adequate skills to function in the community. Literature recommends early, sustained intervention and multiple treatment modalities. For individuals with fluent speech, the focus should be on pragmatic language skills training.  The enrollee has been demonstrating good progress toward goals with her current level of intervention with speech therapy. Prior evaluation showed the enrollee's receptive, expressive and pragmatic language were well below normal limits.  The enrollee made significant progress over the course of one year due to intensive speech therapy.  Despite these improvements, she continues to require intensive help, particularly in pragmatic language.  Due to her dual diagnoses of autism spectrum disorder and attention deficit hyperactivity disorder, she requires extra behavioral support, time to adapt to settings and extra assistance to help her focus and concentrate.  The enrollee had been attending speech therapy with significant improvement.  Continued speech therapy is medically necessary for this patient.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation 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.