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 generator device with eye gaze interaction accessory and mount. The records provided for review document that this patient presents with a history of Rett syndrome, autism, and severe speech apraxia. The patients provider has recommended treatment with a speech generator device with eye gaze interaction accessory and mount. 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. Researchers 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. In a small, published study of the impact of eye-tracking communication on individuals with Rett syndrome and their families, researchers noted that their treating providers observed improved progress toward goals, and parents reported improved psychosocial functioning. Researchers 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. 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. All told, the requested speech generator device with eye gaze interaction accessory and mount is 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.