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

The parent of a three-year-old female enrollee has requested speech therapy 3 times per week for treatment of the enrollees childhood apraxia of speech.  Findings:  The physician reviewer found that language development is one of the most significant processes of early childhood development. 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 parents goals along with the patients clinical needs. Children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, and behaviors. Apraxia of speech is not due to weakness or paralysis of the speech muscles (the muscles of the face, tongue, and lips). The brain has problems planning to move the body parts (e.g., lips, jaw, tongue) needed for speech. The patient knows what he or she wants to say, but his/her brain has difficulty coordinating the muscle movements necessary to say those words.  The severity of apraxia of speech can range from mild to severe. Developmental apraxia of speech occurs in children and is present from birth and can continue into adult life. The National Institute of Health (NIH) reports that children with developmental apraxia of speech will not outgrow the problem on their own. Speech and language therapy is indicated for these children and for people with acquired apraxia who do not spontaneously recover all of their speech abilities. In fact, patients with apraxia of speech usually need frequent and intensive one-on-one therapy. The present literature about childhood speech apraxia indicates an inclination among the researchers that may motivate a mixed therapeutic approach, in which one contemplates not only aspects pertinent to language processing in a phonological representational level, but also aspects related to motor programming and pre-articulatory sequencing of speech itself. When therapy is recommended, the primary goal is to give the patient a reliable way to exchange ideas and information in their daily environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, the patients age, and the etiology of the problem. Research shows that young patients with developmental apraxia of speech have more success when they receive intensive treatment. The literature supports the use and medical necessity of intensive speech and language therapy for verbal apraxia as well as expressive language delay. Although this patient did not carry the diagnosis of childhood apraxia of speech until she was re-evaluated last year, she had already been diagnosed with expressive language delay, justifying speech and language therapy intervention at that time. Now that she has been diagnosed with childhood apraxia of speech, ongoing intensive speech and language therapy continues to be necessary. Given this patients diagnosis of verbal apraxia and documented deficits, speech therapy was medically reasonable and necessary for treatment of her condition. Although the patient has demonstrated improvement in her language skills, she continues to display deficits in the area of expressive language skills. Therefore, the patient should continue to receive speech therapy as recommended by her providers at a frequency of 3 times per week for 48 sessions, followed by a re-evaluation for further services at that time.