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 in-person speech therapy services twice a week for 60 minutes per session. The requested in-person speech therapy services twice a week for 60 minutes per session are medically necessary to treat this patients autism and associated speech deficits. In addition, the requested services are supported to prevent disability and progression of other health conditions. The patient has autism spectrum disorder. Thus, ongoing speech therapy is essential to prevent exacerbation of her disability due to an inability to communicate. Moreover, ongoing speech therapy services twice a week will promote the patients physical and mental health, as well as help ameliorate the patients tantrum behaviors as her ability to communicate improves. Speech therapy is critical to facilitate communication. The patient is highly likely to develop maladaptive behaviors if she is unable to communicate her wants and needs. Baumer and Spence described that treatment of patients with autism spectrum disorder involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. Many parents of children with autism spectrum disorder have described significant problems due to the COVID-19 pandemic. Children with autism spectrum disorder frequently have difficulty attending to telehealth therapy. Manning and colleagues reported stress around therapeutic service disruption in families of children with autism spectrum disorder due to the COVID-19 pandemic. Colizzi and colleagues described that the COVID-19 emergency has resulted in a challenging period for most autism spectrum disorder individuals and their families, with increased difficulties in managing daily activities and at least one in every three children presenting with more frequent or more intense behavior problems. Children with behavior problems predating the COVID-19 outbreak were found to be particularly at risk to present with more intense and more frequent disruptive behavior. This patient presents with speech delays and a diagnosis of autism. Her provider and parent have noticed regression in the patients speech and language abilities since the start of the COVID-19 pandemic, which also marked the start of telehealth services. Prior to the pandemic, the patient was making progress in several domains and completed several reported goals. Given the support in the medical literature, the requested in-person speech therapy services twice a week for 60 minutes per session are medically necessary for treatment of this patient to prevent disability and progression of other health conditions.Final Result: The reviewer determined that the requested services are 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 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.