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

A male who was diagnosed with autism spectrum disorder (ASD). The patient was unable to express colors and nouns, the patient could perform this task. The patient was unable to state his name or age, he could do so with prompting. An Oral and Written Language Scales (OWLS) assessment was performed on 1/2/19. The patients listening comprehension, oral expression and oral comprehension were in the 0.1 percentile. The Preschool Language Scales V was administered. Although the patient scored consistently in the first percentile, he had gained new skills in each interval period. It was noted the patient had severe expressive and receptive language delays. He has been treated with applied behavioral analysis (ABA therapy) and occupational therapy. The patient was reported to participate in therapy, with good functional progress. He used speech to greet others with minimal cues. He was provided with an Augmentive and Alternative Communication (AAC) device. The patients parent requested authorization for one-hour per week of speech therapy services. The Health Plan denied the request and reported that the requested services were not medically necessary for treatment of this patient. At issue in this case is whether the requested one-hour per week of speech therapy services is medically necessary for treatment of the patients medical condition. The records provided for review demonstrate that this patient has ASD with severe expressive and receptive language delays. Although his progress with speech therapy has been slow, he has made documented improvement. The patient has recently been provided with an AAC, and will require training in its use by an appropriately qualified and experienced speech therapist. An AAC device provides a means of effective communication for patients with ASD, many of whom are unable to effectively use conventional speech. Colleagues state the importance of early intervention for children with ASD, emphasizing that developmental and behavioral approaches often underlie the therapeutic strategies employed by speech and language pathologists. Colleagues concluded that behavioral-based interventions to introduce speech to non-verbal patients with developmental disabilities was evidence-based. Treatment of patients with ASD involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech and language, occupational, and physical therapies. Therefore, one hour per week of speech therapy services is medically necessary for treatment of this patients medical condition.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 pediatrics 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.