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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a Tobii Dynavox I-13 speech device (CPT E2510), eye gaze interaction accessory (CPT E2512), and mount (CPT E2599). Fu and colleagues describe Rett syndrome as a severe, progressive neurodevelopmental disorder with multisystem comorbidities that evolve across a patients lifespan, characterized by an initial period of normal development followed by psychomotor regression, deceleration of head growth and development of distinctive repetitive, purposeless hand movements. The period of dramatic psychomotor regression between six and 18 months of age may include loss of language, hand skills, and gross motor function, along with the onset of stereotypical hand movements. Barnes and colleagues note 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. The authors note that there is a high prevalence of anxiety and mood disturbances in Rett syndrome, such as self-abuse, screaming episodes, abrupt mood changes, and inconsolable crying, and report that more severe selective anxiety and mood/disruptive behavior symptoms lead to a worse quality of life. Lim and colleagues explain that rehabilitation and communication interventions in children with Rett syndrome decrease the common symptoms of anxiety, stereotypies, and idiosyncratic behaviors, while increasing caregiver quality of life, given that parents often report psychosocial improvements on learning how to communicate with their children. In recent years, intervention goals for individuals with Rett syndrome have expanded from establishing basic communication skills, such as simple choice-making and requesting, to facilitating a wider range of communicative behaviors and developing reading and writing skills. In a study of the impact of eye-tracking communication on individuals with Rett syndrome and their families, Vessoyan and colleagues found their treating therapists observed improvement on their goals, and that parents reported improved psychosocial functioning. In describing international consensus-based guidelines for the management of communication in individuals with Rett syndrome, Townend and colleagues describe the difficulties in motor movement and motor planning that affect individuals with Rett syndrome and the impact that movement disorders, such as dyspraxia/apraxia and altered muscle tone, may have on an individuals ability to respond. The authors further encouraged the use of multiple strategies and forms of communication, from eye gaze, likely to be the most reliable form of access, to both low and high-tech augmentative and alternative communication. In this patients case, the requested equipment is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested equipment is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested equipment is 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, a Tobii Dynavox I-13 speech device (CPT E2510), eye gaze interaction accessory (CPT E2512), and mount (CPT E2599) is medically necessary for the 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.