Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder.
Treatment: 15 Speech Therapy Visits.
The insurer denied 15 Speech Therapy Visits.
The determination is overturned.

The patient has a history of a chromosomal abnormality, epilepsy, developmental delay and cortical visual impairment. The patient has been diagnosed with autism spectrum disorder. She is non-verbal, and uses a wheelchair. She has severe receptive, expressive and pragmatic language deficits. She was delivered by Cesarean section for a breech presentation. The pregnancy was complicated by polyhydramnios and gestational diabetes. She has had numerous hospital admissions for epilepsy. Surgeries have included gastrostomy tube placement with Nissen fundoplication, adenoidectomy, botulinum toxin injecton to the salivary glands, and bronchoscopy. She has received physical, occupational and speech therapy, together with hippotherapy, craniosacral and music therapy.
She receives speech therapy at school as part of her Individualized Education Plan. An e-mail by her school speech therapist describes that the therapy provided at school is for receptive language only. The patient is asked to demonstrate her understanding of target words by selecting a given item from a choice of two objects.
The patient has also received intensive therapy sessions. The sessions include speech therapy. A note by her speech therapist describes that on the Developmental Assessment of Young Children (DAYC), The patient scored at less than (<) 0.1 percentile for receptive, expressive and combined language. Speech therapy is aimed at improving her receptive, expressive and pragmatic language. A summary from her intensive therapy program describes that the patient had demonstrated emerging ability to use tactile symbols, true object and jellybean switches to request activities, indicate responses to yes/no questions, and give feedback to requests. At issue in this review is the medical necessity of 15 speech therapy visits.

The requested health service/treatment of 15 speech therapy visits is medically necessary for this patient. 

The patient has severe receptive, expressive and pragmatic language deficits. Her speech therapy at school addresses only receptive language. The speech therapy provided at the facility she attends also addresses expressive language with the use of tactile symbols, true object and jellybean switches to request activities, indicate responses to yes/no questions, and give feedback to requests. Development of expressive language is important as it has the potential for her to communicate her wants and needs, and if she is in pain.
The provision of speech therapy is recommended for children with autism spectrum disorder and developmental disabilities which result in severe expressive and receptive language impairment.
Paul [1] stated that "Children with autism benefit from intensive, early intervention that focuses on increasing the frequency, form, and function of communicative acts. Available evidence shows that highly structured behavioral methods have important positive consequences for these children, particularly in eliciting first words." Zwaigenbaum et al [2] review the importance of early intervention (3 years) for children with autism spectrum disorder, emphasizing that developmental and behavioral approaches often underlie the therapeutic strategies employed by speech and language pathologists. Mulhern et al [3] concluded that behavioral-based interventions were evidence-based to introduce speech to non-verbal individuals with developmental disabilities. Baumer and Spence [4] describe 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.
More recently, the Guidelines for the Identification and Management of Children with Autism Spectrum Disorder issued by the American Academy of Pediatrics [5] state: "All children with autism spectrum disorder should have documentation of specific coexisting speech and language diagnoses so that appropriate intervention might be provided. Speech-language therapy is the most commonly identified intervention provided for children with autism spectrum disorder."