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

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with autism spectrum disorder, developmental speech and language disorder, global developmental delay, childhood apraxia of speech (CAS), and mixed expressive-receptive language disorder. The Preschool Language Scale Fifth Edition (PLS-5) placed the patients receptive language age equivalency at one year six months, which was in the first percentile. The patients expressive language age equivalency was placed as one year eight months, which was in the first percentile. A PLS-5 assessment placed that patients receptive language age equivalency at one year 10 months, which was in the first percentile. The patients expressive language age equivalency was two years, which was also in the first percentile. The patients speech was noted to be less than 50% intelligible. Three speech therapy sessions of 30 minutes per week were recommended. The patients parent has requested coverage for five sessions per week of (30-minute) speech therapy sessions with dynamic temporal and tactile cueing (DTTC). The Health Plan denied the request and approved speech therapy three times per week with PROMPT as an alternative. At issue in this case is whether the requested five sessions per week of (30-minute) speech therapy sessions with DTTC are medically necessary for treatment of the patients medical condition. This patients language difficulty is not limited to CAS. He has autism spectrum disorder, with resulting severe delays in both receptive and expressive language. The American Speech-Language-Hearing Association (ASLHA) reports that CAS is a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits. CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known and unknown origin, or as an idiopathic neurogenic speech sound disorder. The impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody. Maas and colleagues stated that the treatment of CAS with a DTTC-type integral stimulation approach has the strongest evidence base, with replicated evidence of efficacy from several well-controlled, single-case experimental design studies from different independent research groups. The medical evidence does not support the requested services in this clinical setting; however, three sessions of speech therapy per week with PROMPT is appropriate. Therefore, the requested five sessions per week of (30-minute) speech therapy sessions with DTTC are not medically necessary for the treatment of this patient. The Health Plan has authorized three sessions per week of speech therapy with PROMPT as an alternative. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with a 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.