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 generating device and accessories (CPT E2510 and E2512). Findings:  The physician reviewer found that records provided for review document that this patient presents with a history of Rett syndrome, and she is non-verbal. The patients provider has recommended treatment with a speech generator device and related accessories. On review of the peer-reviewed medical literature, the requested equipment is medically necessary for treatment of this patient. Rett syndrome is a severe, progressive neurodevelopmental disorder with multisystem comorbidities that evolve across a patients lifespan. Initially, children with Rett syndrome have typical or near-typical development, which can be followed by a period of dramatic psychomotor regression between 6 and 18 months of age, with loss of language, hand skills, and gross motor function, as well as the onset of stereotypical hand movements. Barnes and colleagues described that anxiety-like behavior is a prominent component of the Rett syndrome behavioral phenotype, which affects predominantly children with less severe neurologic impairment and has functional consequences. Lim and colleagues noted that communication interventions in children with Rett syndrome have been shown to decrease the symptoms of anxiety, stereotypies, and idiosyncratic behaviors. In recent years, intervention goals for patients with Rett syndrome have expanded from establishing basic communication skills to facilitating a wider range of communicative behaviors and developing reading and writing skills (Byiers, et al.). In a small, published study of the impact of eye-tracking communication on individuals with Rett syndrome and their families, Vessoyan and colleagues noted that their treating providers observed improved progress toward goals, and parents reported improved psychosocial functioning. Townend and colleagues stated that, Multiple strategies and forms of communication should be encouraged, while recognizing that eye gaze is likely to be the most reliable form of access, to both low- and high-tech AAC, for most individuals with Rett syndrome. An evaluation by a speech therapist specializing in AAC devices has established that this patient has adequate vision, hearing, and cognition for her to be able to use the requested Tobii Dynavox I-13 with Snap Core First software and Gaze Interaction speech generating device. A functional trial of this device indicated that the patient was able to communicate her wants and needs using a nine-icon per page grid using eye gaze, indicating preferred items and activities. She could spontaneously navigate pages as well as answer questions, make greetings, and requests. She was highly interested in using the device. The provider established goals for the patients use of the device over the next few months. For this patient, the requested speech generator device with eye gaze interaction accessory and mount 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. For these reasons, the requested speech generating device and accessories (CPT E2510 and E2512) are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 neurodevelopmental disabilities and 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.