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

The patient is a four-year-old male born via cesarean section at 9 pounds 11 ounces with no complications with the pregnancy or delivery documented.  Developmental history is significant for normal motor development. The patient spoke his first words at 9 1/2 months and began to use two-word phrases at 18 months. He has no feeding difficulties.  The therapy report dated October 2005 documents five episodes of otitis media, a fall requiring stitches to his head but no documented loss of consciousness, and asthma. The results of a hearing exam were within normal limits. The patients mother reports noticing that the patient had difficulty with expressive speech at 18 months of age.  He began speech therapy at age two, initially with hospital-based therapy, and then he transitioned to educationally-based therapy.  He had a speech evaluation from the Center for Speech Pathology in October 2005 that documents a severe phonological disorder with multiple sound substitutions, omissions and distortions. The therapist is recommending speech therapy twice per week.  In addition an evaluation to rule out an apraxia has been recommended. At issue is whether the recommended services are medically necessary.The first issue that needs to be addressed is whether speech apraxia is a disorder or a symptom.  A review of the medical literature to determine if diagnostic criteria have been established to distinguish childhood apraxia of speech as a single entity reveals that there is no literature to support apraxia as a single diagnosis. A paper by Forrest, et. al. demonstrated that there are no consensus criteria and reiterated the ambiguity of the diagnostic criteria of childhood apraxia of speech. Additionally, the US Preventive Services Task Force performed an evidence-based review of screenings for speech and language delay in preschoolers and found the available testing inconclusive.  This study looked at all developmental speech delays; childhood apraxia of speech would be included in this study. Finally, Lewis, et. al. compared children given a diagnosis of childhood apraxia of speech to children with other speech disorders.  The study notes language disorders persist despite a partial resolution of the articulation disorder.  The children with CAS were also at risk for reading and spelling problems. This implies that apraxia is not an isolated disorder, but a symptom associated with other learning and language deficits.  Apraxia of speech is often associated with mild delays in motor development as well (although not in this case).  Neurological exam in these patients is usually normal except for the speech delays.  There is no documentation that demonstrates radiological or other testing is beneficial.  Therefore, in the absence of other neurological signs suggesting an organic cause, it is unlikely that referral to a specialist will be of clinical benefit.  Therefore, an evaluation for apraxia, above and beyond the speech therapy evaluations, is not medically necessary.  Regarding the medical necessity of speech therapy, there is no literature documenting improvement in long-term outcomes from speech therapy for phonological disorders or for apraxia of speech in children.  Also, the Lewis study referenced above found language disorders persist despite a partial resolution of the articulation disorder.  The children with CAS were also at risk for reading and spelling problems. This implies the issues are part of a larger problem.  Historically, these issues have been addressed by the school systems as adjunct therapy through the patients Individualized Education Plan (IEP). Given the fact that these speech issues are part of a more complex learning disability, it makes sense that the speech therapy would be provided as part of a coordinated and comprehensive IEP. There is no justification from a medical standpoint for speech therapy in this case.Based upon the information set forth above, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.