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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy services. Mulhern and colleagues conducted a systematic review of studies in order to examine interventions for teaching speech to individuals who presented as nonspeaking, or with low levels of vocalizations at baseline, and assessed evidence-based practice in this area. They concluded that behavioral-based interventions were evidence-based to introduce speech to non-verbal individuals with developmental disabilities. A review by Baumer and Spence sets forth that treatment of individuals with autism spectrum disorder involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies.Children with ADHD and autism spectrum disorder frequently have difficulty attending to telehealth therapy. One author has noted that many children with autism spectrum disorder have lost previously acquired skills during the coronavirus pandemic (Fox, Eleanor Goldberg). Manning and colleagues have noted that stress around therapeutic service disruption has been reported by families of children with autism spectrum disorder due to the coronavirus pandemic.In this case, prior to transition to telehealth due to the coronavirus pandemic, the patient had met 3/6 goals in his 1:1 speech therapy sessions. At the patients two most recent evaluations, the patients therapist recommended continuing speech therapy for a further 6 months at the current level (two 60-minute sessions of 1:1 speech therapy and one 60-minute session of group speech therapy per week). Testing comprising the Clinical Evaluation of Language Fundamentals, Preschool 2nd edition  (CELF-P2) showed scattered results for the patient, but some areas of progress were presented, including in the domains of word classes and recalling sentences. The patient's mother describes significant functional progress since the patient has been receiving speech therapy. She describes that when the patient started to receive speech therapy four years ago, the patient was using only single words. He is now able to use complete sentences, and uses words to express his wants and needs. Given the therapeutic service disruptions presented by the coronavirus pandemic, it is inappropriate to determine that the patient has had insufficient progress in the last evaluation period, as his therapy transitioned to telehealth. Under these circumstances, the requested speech therapy services are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's 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.