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 in-home speech therapy services twice a week, one hour per session. Current medical literature supports the use of ongoing speech therapy in the treatment of patients with autism spectrum disorder (ASD) with significant impairment of receptive and expressive language. Zwaigenbaum and colleagues recommend early intervention for children with ASD, emphasizing that developmental and behavioral approaches often underlie the therapeutic strategies employed by speech and language pathologists, even under three years of age. In a systematic review, Mulhern and colleagues conclude that behavioral-based interventions are evidence-based to introduce speech to non-verbal individuals with developmental disabilities. Hyman and colleagues report, 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. In this case, the patient has ASD. The records document testing results showing impairment and delay in receptive and expressive language. The impairment affects the patients behavior, resulting in frustration and physical aggression when he is unable to communicate. In this patients case, 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. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. 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. Therefore, in-home speech therapy services twice a week, one hour per session are medically necessary for the treatment of this patient.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.