Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Developmental disorder of speech and language. 
Treatment: Speech therapy 2 visits. 

The insurer denied coverage for speech therapy 2 visits. 

The denial is overturned. 

According to the documentation submitted, this is the case of a young toddler with a history of developmental disorder of speech and language. The patient had a speech evaluation due to developmental disorder of speech and language. Impression stated that according to standardized assessment, the patient has significantly decreased functioning for receptive language and expressive language skills. This indicates severely delayed language functioning. subsequent sessions was recommended. 

Language disorders are one of the four disorders classified under communication disorders by Diagnostic and Statistical Manual (DSM)-V. The other three are speech disorders, central auditory processing disorders and hearing disorders. Communication disorders, which may have a severity range from mild to profound, interfere with an individual's ability to function in daily life (American Speech-Language Association, 1993). At any age, stroke, brain injuries, disease or seizures may lead to communication disorders. 

Expressive language disorders involve deficits in verbal and written expression. Deficits may involve articulation, vocabulary, sentence formation and memory. A child's language ability will lag that of his/her peers in areas such as word choice and usage, sentence formation and grammar. Receptive language disorders involve deficits in comprehension. In children, signs may include not listening to or following instructions and repeating words or phrases heard, a symptom called echolalia. Mixed Receptive-Expressive Language Disorder involves problems with both expressive and receptive communication. Many individuals experience deficits in both areas. An individual may also show signs of dyscalculia (problems with arithmetic) or spatial concepts. 

- Forms of Language - involve phonology (speech sounds and patterns), morphology (how words are formed) and syntax (the formation of phrases and clauses). 
- Content of Language - involves semantics or the meanings of words. 
- Function of Language - involves pragmatics or how language is used by individuals in different contexts. 

The assessment by the speech language pathologist (SLP) in this case, was performed through and utilized a well-respected, evidence based tool (Rosetti Infant-Toddler Language Scale). The Rosetti is a criterion reference instrument designed to assess the language skills of children. The scale assesses preverbal and verbal areas of communication and interaction: Interaction-Attachment, Pragmatics, Gesture, Play, Language Comprehension and Language Expression. 

Per this assessment, this child has a significant developmental (and potentially neurodevelopmental) disorder in all aspects of language described above.  This is not a delay, which may improve with further growth and development, but a true disorder which requires direct treatment by a licensed professional to address. Given the deficits in pragmatic and social language and non-verbal communication, further assessment should be considered. 

In a scoping review of evidence re: DLD (developmental language disorders), the conclusion of the literature recommended early assessment and targeted intervention by a licensed speech-language pathologist has been proven to result in significant benefit for the patient and their communicative partners. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  

The medical necessity for Speech Therapy, 2 visit(s) is substantiated.