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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for authorization and coverage for a Tobii Dynavox I-13 Speech Device (CPT E2510), an eye gaze interaction accessory (CPT E2512), and a mount (CPT E2599).Graziola and colleagues have explained that children with GNAO1 mutations usually need to use a wheelchair and have numerous motor constraints, including dystonic movements and postures and hypotonia, making cognitive assessment difficult. This contributes to their disability, resulting in a high level of frustration for both caregivers and patients. Graziola and colleagues evaluated six children with GNAO1 mutations and found that these children showed variable degrees of communicative intent through intentionally directed gaze. Importantly, three of the children were able to complete a cognitive evaluation and showed normal fluid intelligence and lexical comprehension. The authors concluded that in GNAO1-related disorders, the degree of cognitive development is underestimated. The authors also concluded that eye tracking technologies may help in overcoming these boundaries.A Position Statement by the American Speech-Language-Hearing Association (ASHA) states that eligibility policies and practices often preclude children and adults with severe disabilities from accessing needed communication services and supports. The authors state, `It is the position of the National Joint Committee for the Communication Needs of Persons With Severe Disabilities that eligibility for communication services and supports should be based on individual communication needs. Communication services and supports should be evaluated, planned, and provided by an interdisciplinary team with expertise in communication and language form, content, and function, as well as in augmentative and alternative communication (AAC).`The provision of an AAC device is regarded as evidence-based standard of care for individuals with intellectual disability who are evaluated and found to be capable of using a device. Morin and colleagues conducted a systematic review and found that 18 multiple-baseline or multiple-probe experiments across 17 studies indicate that using high-tech AAC to teach social-communication skills to individuals with autism spectrum disorder or intellectual disabilities and complex communication needs can be considered an evidence-based practice.In this case, the patient has a mutation of GNAO1, with resultant chronic encephalopathy, severe expressive speech impairment, hypotonia and choreoathetosis. The requested Tobii Dynavox I-13 Speech Device (HCPCS Code E2510), eye gaze interaction accessory (HCPCS Code E2512), and mount (HCPCS Code E2599) are necessary to treat the patients symptoms of severe expressive language disorder. The patient is at present unable to communicate, and he has had regression in his communication skills during the time that he has been denied access to the Tobii Dynavox device, with whining and frustrated behavior. The device will minimize progression of the symptoms of his underlying GNAO1 mutation, which has resulted in severe expressive language disorder, which is listed as a mental health diagnosis in both ICD-10 (F80.2) and DSM-5 (315.32). The requested device is also clinically appropriate, as less sophisticated devices have been found to be inadequate for the patient. His severe choreoathetosis precludes functional use of his hands, and he needs a device with eye gaze technology which is speech generating. The requested equipment is also 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. Accordingly, the requested Tobii Dynavox I-13 Speech Device (CPT E2510), eye gaze interaction accessory (CPT E2512), and mount (CPT E2599) are medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the requested equipment is medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology, with subspecialty certification 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.