Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Expressive and receptive language delay
Treatment: Speech therapy; 92507 - Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual

The 92507 - Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual was not medically necessary.

Initial habilitative therapy for language delay/disorder is indicated when ALL the following are present [Paul 2012, Stene-Larsen 2014, Berkman 2015, Collisson 2016]:
1) Diagnosed medical condition, as indicated by 1 or more of the following: a) Autism spectrum disorder, based on rigorous diagnostic evaluation that relies on both the ADOS-2 and DSM-5 administered by a qualified diagnostician [Met; however, the private SLP did not recognize or mention this diagnosis.] b) Central nervous system infection (eg, herpes encephalitis) c) Cerebral palsy d) Epilepsy or other seizure disorder e) Fetal alcohol spectrum disorder f) Genetic syndrome or chromosomal anomaly, with associated language disorder g) Hearing loss h) Inborn error of metabolism (eg, phenylketonuria, galactosemia) i) Intellectual disability j) Language-based learning disability (eg, dyslexia) k) Premature birth (born before 37 weeks' gestation) or low birth weight (< 5th percentile for gestational age) l) Expressive language or receptive-expressive language delay or disorder [Met] m) Speech articulation delay or disorder n) Specific language disorder 2) Patient is age 12 years old or less, as this is the age at which all children reach their maximum potential and after which there is insufficient evidence to support continued therapy [Met] 3) Recent change in language status, as indicated by 1 or more of the following: a) Change of symptoms or function in patient with previous chronic or stable pediatric or developmental language disorder b) Recent diagnosis of medical condition c) Recent diagnosis of speech or language delay/disorder for which the patient has not previously received speech therapy [Not met.] 4) Significant impairment of function relative to developmental normative data as indicated by ALL the following: a) Below average or significantly discrepant performance, as determined by 1 or more of the following: 1) on standardized testing: a) standard score or developmental quotient < 85 [Met] b) scaled score < 7 c) T-score < 40 d) percentile < 16 e) difference of > 1 standard deviation (SD) between receptive and expressive language: b) standard score > 16 points c) scaled score > 3 points d) T-score > 10 points 2) informal evaluation of speech intelligibility at the conversational level reveals one of the following: a) Age 24 months: < 40% (50% is normal) b) Age 36 month: < 65% (75% is normal) c) Age 48 months: < 85% (100% is normal) 3) if child is uncooperative for testing or lacks the skills needed for testing, the narrative clearly describes below average skills (e.g., 2-year-old who is nonverbal; 5-year-old who speaks using single words) a) AND 1 or more of the following: 1) Decreased ability to recall specific content of information read or heard 2) Decreased expressive and/or receptive vocabulary [Met] 3) Decreased oral and written language comprehension, processing, and expression 4) Decreased preliteracy or literacy skills 5) Decreased sentence or utterance length and complexity 6) Decreased social communication skills or pragmatic deficits 7) Difficulty organizing, planning, and formulating content of oral and written expressive language 8) Difficulty with syntax and grammar in oral and written language 9) Decreased intelligibility 10) Goals for speech therapy are concise, specific, objective, and directly measurable [Not met]

The clinical records submitted for review fail to document the patient meeting all above criteria.  The patient qualified for ST through the state's Early Intervention program just one month prior.  Receiving ST from the private SLP would duplicate those services. Also, the goals for speech therapy are not concise, specific, objective and directly measurable. Thus, ST from the private SLP is not medically necessary, appropriate, or the standard of care.