Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for continuation of speech therapy. Researchers report, Because of the COVID-19 pandemic, in-person services for individuals with neurodevelopmental disabilities were disrupted globally, resulting in a transition to remote delivery of services and therapies. For individuals with neurogenetic conditions, reliance on nonclinical caregivers to facilitate all therapies and care was unprecedented. The authors continued, In general, most caregivers did not find online therapies beneficial for their dependent. The authors further noted, A concern of the continued lack of in-person professional supportive services is that dependents may experience a loss or plateau of skills previously acquired. The long-term effects on skill development is unknown, especially for younger children, nor is it known how long it will take for dependents to regain their skills if they are lost due to disruptions to service.Researchers report that peer relations are a vulnerable area of functioning in children with specific language impairment and that the risk of poor trajectories of peer relations is greater for children with pragmatic language difficulties. In an investigation of the effect of speech therapy with an emphasis on pragmatic language, researchers reported significant treatment effects were found for blind-rated perceptions of conversational competence, for parent-reported measures of pragmatic functioning and social communication, and for teacher-reported ratings of classroom learning skills. In this case, the patients most recent scores on the CELF-5 indicated that he was in the 12th percentile for receptive core language (an improvement from the 1st percentile that he was in during the pandemic when he was receiving telehealth services) and in the 16th percentile for expressive language. These were improvements compared to scoring  when the patient was in the 5th and 9th percentiles. The patients pragmatic language score was extremely low, below the 0.4th percentile, which likely explains his difficulty starting and maintaining conversations. The records noted that the patient has struggled with telehealth speech therapy during the pandemic due to difficulties with attention. In this clinical setting, a further six months of face-to-face speech therapy, with an emphasis on pragmatic language and a re-evaluation at the end of that time, is medically indicated. Therefore, continuation of speech therapy is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology, 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.