Apraxia Of Speech: when insurers say no, reviewers often say yes
In 19 published external-review decisions involving apraxia of speech, independent physician reviewers overturned the insurer’s denial 89.5% of the time.
Most-fought treatments for apraxia of speech
| Treatment | Decisions | Overturned |
|---|---|---|
| Speech Therapy | 13 | 92.3% |
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prosptective authorization and coverage for speech therapy. Findings: The physician reviewer found that The ability to communicate effectively with others is central to children's development. Delays or disruptions due to isolated expressive language delay, articulation errors, multiple sound production errors with motor planning deficits, or mixed expressive and receptive language delay, often bring widespread consequences.” Capone Singleton reports that late talking children who do not receive professional intervention are placed at risk for life-long disability. O’Hare and Bremner emphasize the need for comprehensive speech and language assessment, along with speech therapy, for children with speech and language difficulty.
The parent of a three-year-old male enrollee has requested speech therapy five hours a week (home based), physical therapy one hour a week, and occupational therapy two hours a week for treatment of the enrollee’s autism. Findings: The physician reviewer found that 1. Is speech therapy for five hours a week (home based) medically necessary? The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have autism spectrum disorders. In this particular case, the patient suffered a left frontal lobe stroke which in 95% of the population is the dominant hemisphere and controls Broca’s area which is essential for speech.
Where the denial was upheld
The parents of a six-year-old female enrollee requested authorization and coverage of speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollee’s apraxia of speech.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plan’s denial on the basis that the requested therapy is not medically necessary.
The parents of an eight-year-old male with apraxia of speech are requesting coverage of SPECT scan and doppler vasodilators. Reviewer’s Findings: The reviewing physician found that SPECT scans and vasodilators are not standard treatment for apraxia of speech or developmental delay. The Health Plan denial was upheld.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for apraxia of speech was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY