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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for two additional speech therapy sessions per week (for a total of five speech therapy sessions per week).Medical literature shows that delayed language is an early concern for many children who are later diagnosed with autism spectrum disorder (ASD). The authors state that speech-language therapy is the most commonly identified intervention provided for children with ASD. The guidelines do not specify an optimal intensity/dosage of speech therapy. In another study,  researchers reviewed a total of 233 children with language impairment on the caseloads of 73 speech-language pathologists (SLPs) and concluded that more intensive language treatment, measured as time, is not necessarily associated with better treatment outcomes. In another study, researchers examined the association between dose, intensity, and effect size in 20 randomized controlled studies and found that dosage, however defined, was not directly associated with outcome, although the level of association varies across the three interventions, for example appearing stronger for vocabulary and phonology than syntax. The authors concluded that given the available data, it is not, at this stage, possible to make recommendations about optimal dosage. Researchers reviewed 60 studies and found that the summary effect of intervention on language outcomes was small but significant. They also found that the effects were not moderated by cumulative intervention intensity or intervention type.In this case, speech therapy reports reflect that the patient has made minimal progress while receiving speech therapy four times per week over a period of time. Reports indicate that the patient has met 2 out of 5 goals and that they only use their AAC device at home to request food and drink items. The medical literature supports the conclusion that it is unlikely that additional weekly sessions of speech therapy will result in faster progress for the patient. As noted above, researchers concluded that more intensive language treatment, measured as time, is not necessarily associated with better treatment outcomes. Additional researchers also concluded that given the available data, it is not, at this stage, possible to make recommendations about optimal dosage. Therefore, general standards of care do not support speech therapy five times per week for children with autism spectrum disorder, and speech therapy five times per week is not supported in the medical literature. Accordingly, the two additional speech therapy sessions per week (for a total of five speech therapy sessions per week) are not medically necessary to treat the patients condition. The requested services are not medically necessary to prevent disease, disability, and other health conditions or their progression. The requested services are not medically necessary to prolong life or to promote physical and mental health and efficiency. Additionally, the requested services are not medically necessary to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested two additional speech therapy sessions per week (for a total of five speech therapy sessions per week) are not medically necessary to treat the patients condition. The requested services are not medically necessary to prevent disease, disability, and other health conditions or their progression. The requested services are not medically necessary to prolong life or to promote physical and mental health and efficiency. Additionally, the requested services are not medically necessary to correct or ameliorate any physical or behavioral conditions.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology, with subspecialty certification in neurodevelopmental disabilities, 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.