Articulation Disorder denials in California external review

What the reviewers wrote

Where the denial was overturned

The parent of a seven-year-old male enrollee has requested speech therapy for treatment of the enrollee’s articulation disorder. Findings: The physician reviewer found that based on the records provided, this patient has a serious articulation deficit that places him approximately two years behind his peers. He is intellectually normal or above normal, so his articulation defect is not due to a developmental delay, but is secondary to a neurological dysfunction of his brain/oral pharynx/tongue network. Consistent with the publication from Tyler, this patient’s difficulties stem from this abnormality in his nervous system. Further, Sharp and Hillenbrand state that reviews of the literature indicate the necessity and effectiveness of speech therapy in children over the age of three-years of age with articulation defects.

The patient’s parent has requested authorization and coverage for speech therapy services (a reevaluation for speech therapy and two 60-minute sessions per week). Liu and colleagues note, “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.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s language skills as assessed by the Clinical Evaluation of Language fundamentals-5 were within the typical range of development. An assessment of fluency was also within the typical range of development, although monitoring was suggested. The primary area of concern was speech sound development. Testing that utilized the Goldman Fristoe Test of Articulation-3 noted errors that included the following sounds: /r/; vocalic /r/; /th/, /dz/, as well as some idiosyncratic errors on /t/ and /b/. He also had a rapid rate of speech, which decreased intelligibility. Progress reports documented limited progress in the acquisition of the /r/ and vocalic /r/ sounds, and noted improvement in the production of multisyllabic words /th/ sound and reduction of the rate of speech.

The patient is a six-year-old female with a history of expressive and receptive language deficits and a severe articulation disorder. Other diagnoses as stated include apraxia, auditory processing dysfunction, speech disorder and lack of coordination. The patient has been receiving speech therapy for the above dysfunctions since July 2002. Her parents have requested retrospective coverage and reimbursement for speech therapy provided twice per week as well as on-going authorization at the same frequency. The Health Plan denied the request based on a determination that the therapy at issue was/is not medically necessary.I have reviewed the literature regarding speech therapy in auditory processing disorders and apraxia of speech. The most apparent finding is that there is little consensus regarding the diagnoses of apraxia of speech or auditory processing disorder.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving articulation disorder, then check the rights and deadlines that apply to your plan.