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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for continuation of speech therapy services, individual treatment of speech, language, voice, communication, and/or auditory processing disorder, and/or self-care management training. The records provided for review support partial approval of the requested speech therapy services for this patient with continuation of speech therapy services, 16 units each of individual treatment of speech, language, voice, communication, and/or auditory processing disorder to address the patients ongoing speech sound disorder. In a recent review on the treatment of speech sound disorders in children, researchers performed a meta-analysis of 12 studies. The authors concluded that complexity-based treatments had a substantial effect on a patients ability to produce complex speech sounds. This patients records document that the Goldman Fristoe Test of Articulation (GFTA) was administered, and the patient scored at below the first percentile, consistent with a moderate-to-severe speech sounds disorder. The records do not include documentation of repeat administration of the Goldman Fristoe Test of Articulation for comparison. The progress notes state that the patient is still having difficulty accurately pronouncing words with more than three syllables, with accuracy in only 6 of 10 trials. The patients six-month short-term goal was for 90% accuracy. Based on the available documentation, the patient has a speech sound disorder. Therefore, the requested speech therapy services, individual treatment of speech, language, voice, communication, and/or auditory processing disorder is medically necessary for treatment of this patient. With regards to the requested self-care management training, the records suggest that the self-care management training refers to the Barton Reading and Spelling Program. As noted in the medical literature, the Barton Reading and Spelling Program is educational in nature, and is aimed at treating dyslexia. The U.S. Department of Education (DOE) indicated that, The Barton Reading and Spelling System is a one-to-one tutoring system designed to improve the reading, writing, and spelling skills of children, teenagers, or adults who struggle due to dyslexia or another learning disability. In addition, the DOE noted that they are unable to draw any conclusions based on research about the effectiveness or ineffectiveness of the Barton Reading and Spelling System on students with learning disabilities. Thus, self-care management training is not medically necessary for this patient. Moreover, the requested speech therapy services, individual treatment of speech, language, voice, communication, and/or auditory processing disorder is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. The requested self-care management training does not meet these requirements. Given these findings, the requested continuation of speech therapy services, individual treatment of speech, language, voice, communication, and/or auditory processing disorder is medically necessary for this patient while the requested self-care management training is not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology with expertise in neurodevelopmental disabilities 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.