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

The parent of a four-year-old female enrollee has requested  speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that language development is one of the most significant processes of early childhood development. Developmental delay often accompanies delayed speech development. Speech development is an important predictor for later problems, such issues with reading and spelling, among other learning difficulties. Different researchers describe children with delayed speech development as being highly at risk of other cognitive, social-emotional, and school-related problems. In the medical literature, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. Differential diagnosis is critical to designing appropriate intervention, which should be tailored to the goals based upon the patients clinical and educational needs. While most patients difficulties resolve, those with difficulties that persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.Shevell looked at children under 5 years of age, referred over an 18-month period to subspecialty services for initial evaluation of a suspected developmental delay. Overall, 99 children were found to have global developmental delay with an etiologic diagnosis determined in 44 patients. The authors concluded that an etiologic diagnosis is often possible in the young child with global developmental delay, particularly in the absence of autistic features. The patient in this case does not have any evidence of autism. However, the Plans provider did not look for an etiology of the speech delay and had they looked for one they may have found one that would qualify for therapy. Similarly, the American Academy of Neurology (AAN) practice parameters recommends evaluation of young patients with non-progressive global delay to determine a specific etiology. Certain routine screening tests are indicated and depending on history and examination findings, additional specific testing may be performed which were not conducted in this case. Research also shows the patients with developmental apraxia of speech have more success when they receive frequent (3-5 times per week) and intensive treatment. Patients seen alone for treatment tend to do better than those seen in groups, yet as the patient improves, they may need treatment less often, and group therapy may be a more suitable alternative. In a meta analysis by Morgan and Vogel, the review shows that there is a positive effect of speech and language therapy interventions for young patients with expressive phonological and expressive vocabulary difficulties. All told, speech therapy is medically necessary for this patient based on the evidence in the literature and should be provided for a minimum of five hours per week. In addition, a detailed and complete speech and language evaluation should be performed by an independent therapist for an accurate diagnosis. A work-up should also be performed to look for possible etiology of the speech delay.