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 speech therapy (one 50-minute visit weekly). The American Speech-Language-Hearing Association (ASHA) notes that the goal of intervention with augmentative and alternative communication (AAC) is to maximize the efficiency and effectiveness of communication for individuals who are unable to communicate via verbal speech, with intervention taking place in a naturalistic environment in order to promote generalization and functional use whenever possible. ASHA notes that potential areas of focus for treatment include using AAC to improve functional communication, increase language and literacy skills, improve speech production and comprehensibility with the use of multiple modalities, decrease challenging behaviors, and improve social communication. ASHA further notes that AAC intervention requires ongoing collaborative decision making and training to promote communicative competence and language and literacy development and may include customization of vocabulary, rate enhancement features that allow users to produce language with fewer keystrokes, and updates to software for high-tech devices. Researchers explain that AAC interventions address the development of adequate, functional communication skills to support individuals with complex communication needs in developing, rebuilding, or sustaining communicative competence to express needs and wants, develop social closeness, exchange information, and participate in social etiquette routines. In this case, a speech-language pathology progress report dated July of 2021 reported that the patient had made significant progress, meeting all four of her speech therapy goals with her SGD, including using 3+ word utterances in 50% of opportunities, improving syntax skills by using 3+ word complete sentences including pronouns in 50% of opportunities, using 3+ word utterances to express negation in 50% of opportunities, and improving pragmatic language to the point of responding appropriately in 50% of opportunities. The records noted that the provider updated the patients goals, reported that the patient had demonstrated significant progress, was engaged for the majority of telehealth visits, and recommended continued speech therapy. While many children with developmental disabilities have had regression of skills during the COVID-19 pandemic due to difficulty cooperating with teletherapy sessions, it is particularly noteworthy that this patient has made significant progress in her ability to use her ACC device during the pandemic, as all of her speech therapy appointments were by teletherapy. In this clinical setting, given that ongoing speech therapy is crucial for the patient to continue to improve her communication skills using the AAC device, the requested services are medically indicated. Therefore, speech therapy (one 50-minute visit weekly) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology with sub-specialty 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.