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

Nature of Statutory Criteria/ Case Summary: Findings the physician reviewer found that  coverage for speech therapy, three times per week at 30 minutes per session. The  enrollee has a history of hypoplastic aorta syndrome, hypoplastic left heart syndrome, ventricular septal defect, and two strokes. After the second stroke, he has diagnoses of chorea, apraxia, developmental delay, and speech delay. He has been receiving speech therapy services for mixed receptive-expressive language, dysphagia, and phonological disorder. At school, he receives speech and language services two times per week as part of his special education program.  He continued to receive outpatient speech therapy to increase lingual and labial strength, rate, coordination, and range of motion; increase fluency and intelligibility; improve grammar and syntax, and; improve comprehension of compound negative sentences. He had improved in rhyming and segmentation. Re-evaluation showed mildly delayed receptive language skills, severely delayed expressive language, and functional gains in sentence length, semantic knowledge, and narrative abilities. According to current literature, a deficit, such as childhood apraxia of speech, is a neurologically based deficit in which the precision and consistency of movements of underlying speech are impaired. A speech therapy program begins with an initial comprehensive evaluation and establishment of a care plan with formal re-evaluation every three to four months and treatment plan modifications, as indicated.  Within the record, notes indicate the enrollee has been receiving speech language therapy services for several years.  Notes indicate benefit was being made but does not indicate the enrollee will restore function with ongoing speech-language therapy participation.   The enrollee has had numerous years of therapy to correct deficits. In the record, six goals listed are the same as stated in previous years.  Out of the eleven goals listed, ten goals were not met as stated. The eleventh goal was discontinued. On three goals, it was reported the enrollee either maintained his status from the prior report period or goals were not addressed in that report period. A re-evaluation performed by his speech therapist, included testing in direct correlation to past assessments. There was no significant improvement exhibited from previous tests. She indicates the enrollee demonstrated intelligible speech despite articulation distortions, he was safe with thin liquids, and he was able to convey his needs. She conducted family training with the parents and recommended a re-evaluation in one year from the date of her re-assessment. The records do not indicate the enrollee will restore function with ongoing speech therapy participation.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.