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

The patient is a three-year-old male with a history of speech delay without expressive or receptive language delay.  Specifically, the speech delay is an articulation disorder with severe oral-motor discoordination and apraxia.  The patient also has multiple sound omissions, substitutions and distortions.  In addition, the patient has been evaluated by an occupational therapist and found to have feeding, coordination, vestibular and sensory processing difficulties.  The patient has oral aversions and has had issues with coughing and vomiting associated with eating.  At issue is whether the recommended speech and occupational therapy are medically necessary.The literature submitted in support of the requested speech therapy is primarily professional opinion and is not supported by scientific data. Furthermore, review of the scientific literature reveals no data to support childhood apraxia of speech (CAS) as developmental or neurological in nature. Nor is there any literature that distinguishes CAS as an entity in and of itself. A single article of small study size documents the deficits associated with CAS, but also documents that other learning disabilities including reading and spelling problems are associated with the apraxia. It also concludes language problems persist despite partial resolution of articulation problems. This suggests that the issues related to the symptoms of apraxia are broader than an articulation disorder and are long-term in nature. Moreover, although the American Speech-Language Hearing Association (ASHA) recognizes CAS as a neurological disorder, it provides no scientific evidence to support the assumption. ASHA also provides no scientific literature that speech therapy is beneficial in treating CAS.  Apraxia of speech is broader reaching than the inability to formulate words and includes other language and learning issues, which are more appropriately dealt with in the school system and are educational in nature.  Therefore, I find the requested speech therapy is not medically necessary.  Regarding occupational therapy, a review of the literature reveals no evidence of efficacy of occupational therapy in the treatment of vestibular dysfunction, sensory processing and motor apraxia.  The literature on sensory integration techniques includes small case series that are unblinded with short-term measures and lacks adequate outcomes data to show long-term benefit.  Regarding swallowing issues, the occupational therapy evaluation from June 2006 documents that the patient vomits 2-3 times per week while feeding.  Additionally, the therapist documents Colin gags frequently during feeding, but clears and swallows efficiently without indication of silent aspiration or dysphagia.  He tends to overstuff when self-feeding.  His weight was also described as appropriate for his age and he has no history of pneumonia. This description implies a behavioral response to feeding (over-stuffing) rather than a medical indication based on a concern for aspiration.  These issues can and should be addressed as part of an all-encompassing plan through the patients Individualized Education Plan. Thus, there is no medical necessity for the requested occupational therapy.For the reasons set forth above, I have determined the requested therapies are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.