Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for an additional four (4) sessions per week of speech therapy (for five sessions/week total). The American Academy of Pediatrics guidelines on the identification, evaluation, and management of children with autism spectrum disorder (ASD) describes delayed language as an early concern for many children who are later diagnosed with ASD, and that the communication symptoms included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for ASD reflect core deficits in social communication and interaction including failure of back-and-forth communication, deficits in nonverbal communication such as eye gaze and use of gesture, difficulty adjusting behavior to suit the social context, and restricted and repetitive behaviors leading to perseverative vocalization, echolalia, and preoccupation with restricted topics of interest. While the guidelines note that speech-language therapy is the most commonly identified intervention provided for children with ASD, they do not specify optimal intensity/dosage of speech therapy. In an examination of treatment intensity delivered to 223 children with language impairment, Schmitt and colleagues concluded that the findings suggested that more intensive language treatment, measured as time, was not necessarily associated with better treatment outcomes. In an examination of the association between dose, intensity, and effect size in 20 randomized controlled studies taken from a few systematic reviews focusing on interventions aiming to ameliorate vocabulary, phonology, and syntax, researchers reported, Dosage, however defined, is 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, Given the available data, it is not, at this stage, possible to make recommendations about optimal dosage. In a study synthesizing the effects of interventions on language outcomes of children up to eight years of age with autism and evaluating the extent to which summary effects varied by intervention, participant, and outcome characteristics, researchers found that the summary effect of intervention on language outcomes was small but significant, and that effects were not moderated by cumulative intervention intensity or intervention type. In this clinical setting, given that current medical literature does not support the need for additional speech therapy sessions, the requested services are not medically indicated. Therefore, an additional four (4) sessions per week of speech therapy (for five sessions/week total) are not medically necessary to prevent disease, disability, and other health conditions or their progression.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology with sub-specialty 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.