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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for in-home speech therapy services twice a week, one hour per session.At issue is whether in-home speech therapy services twice a week, one hour per session are medically necessary to treat the patients condition as defined in Health and Safety Code section 1374.72(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) 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.Provision of speech therapy to children with autism spectrum disorder is considered the standard of care and medically necessary. Paul stated that, Children with autism benefit from intensive, early intervention that focuses on increasing the frequency, form, and function of communicative acts. Available evidence shows that highly structured behavioral methods have important positive consequences for these children, particularly in eliciting first words. (Paul, R.). Zwaigenbaum and colleagues reviewed the importance of early intervention for children with autism spectrum disorder, emphasizing that developmental and behavioral approaches often underlie the therapeutic strategies employed by speech and language pathologists. (Zwaigenbaum, L., et al.). Mulhern and colleagues concluded that behavioral-based interventions were evidence-based to introduce speech to non-verbal individuals with developmental disabilities. (Mulhern, T., et al.) Hyman and colleagues describe that treatment of individuals with autism spectrum disorder involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. In a recent clinical report outlining management of children with autism spectrum disorder (ASD), the American Academy of Pediatrics recommended speech therapy as a standard of care, stating, Speech-language therapy is the most commonly identified intervention provided for children with ASD. The strategies used by speech-language pathologists to reinforce sound repetition and word use in children with typical development are often initially used with young children with ASD. Such strategies include reinforcement of speech sounds and communicative acts, imitation of the sounds the child makes, and exaggerated imitation and slowed tempo. The literature offers the most support for approaches with preverbal children with ASD in which adult prompts are used for communication, prompt fading, and reinforcement of their own attempts at communication. Intervention in naturalistic settings and involvement of caregivers may help reinforce the initiation of communication and functional use of sounds, gestures, and words. (Hyman, S., et al.). In this case, the patient has significant impairment of receptive and expressive language. This is causing impairment of his ability to communicate. Thus, the requested in-home speech therapy services twice a week, one hour per session are medically necessary to treat the patients medical condition. Specifically, the requested in-home speech therapy services twice a week, one hour per session are in accordance with the generally accepted standards of mental health and substance use disorder care. The requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. Additionally, the requested services are 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.Final Result: The reviewer determined that the requested services are 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 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.