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

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with autism spectrum disorder, intellectual disability, feeding problems, global developmental delay, developmental language disorder, and bilateral intermittent exotropia. The patient was born at 40 weeks gestation by caesarian section following a failed induction. The pregnancy was complicated by hypertension, obesity, and asthma. At birth the patient had severe respiratory distress due to persistent pulmonary hypertension, and was placed on extracorporeal membrane oxygenation (ECMO) for five days. A magnetic resonance imaging (MRI) of the patients brain, at 11 days of age, showed an intraventricular hemorrhage. He was diagnosed with autism spectrum disorder at 18 months old. The Preschool Language Scales Fifth Edition that was administered showed auditory comprehension, expressive communication, and total language scores placed the patient in the first percentile at one year and three months. The test was re-administered and showed auditory comprehension of two years three months, expressive communication of one year five months, and total language of one year 11 months. The results continued to place the patient in the first percentile. A speech therapy evaluation of the patients progress reported that the patient was more verbal and enjoyed interacting more. He was more willing to comply with instructions. The patient could identify greater than 50 nouns and greater than 10 verbs 71% of the time. At baseline, he could use a consonant-vowel-consonant combination 50% of the time, and on reassessment he could perform this task 69% of the time. A speech therapist reported the patient would not benefit from further weekly speech therapy sessions, and recommended a home program. The patient had been receiving speech therapy once per week. At issue in this case is whether individual weekly speech therapy twice per week was medically necessary for treatment of the patients medical condition and whether 50 minutes of speech therapy twice per week or 50 minutes of speech therapy once per week is medically neceessary for treatment of the patients medical condition. Deficits in vocal speech are common among patients with developmental disabilities. A study found a variety of interventions, primarily behavioral, intended to induce vocal speech for patients with developmental disabilities aged between six months and 57 years. The researchers found that behavioral interventions constituted evidence-based practice for patients with developmental disabilities. Comorbidities commonly seen with autism spectrum disorder include medical, neurologic, and psychiatric conditions. Treatment involves intensive behavioral therapy and educational programming, along with traditional ancillary services, such as speech and language, occupational, and physical therapies. In this case, the patient has moderate to severe expressive and receptive language impairment due to autism spectrum disorder. A speech therapy evaluation reported the patients cooperation with therapy was improving, and that he was making progress. Therefore, individual weekly speech therapy that was provided was medically necessary for the patient. In addition, 50 minutes of speech therapy once per week is also medically necessary for the patient, while 50 minutes of speech therapy twice per week is not medically necessary for the patient. Final Result: The reviewer determined that the requested services were partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology with specialty 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.