Childhood Apraxia Of Speech: when insurers say no, reviewers often say yes

Where the denial was overturned

The parent of a three-year-old female enrollee has requested speech therapy 3 times per week for treatment of the enrollee’s childhood apraxia of speech. Findings: The physician reviewer found that language development is one of the most significant processes of early childhood development. Speech and language development should be consistent with a patient’s overall development and can be tracked using typical milestone markers. Differential diagnosis is critical to designing appropriate intervention, which should be tailored to the parents’ goals along with the patient’s clinical needs. Children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, and behaviors. Apraxia of speech is not due to weakness or paralysis of the speech muscles (the muscles of the face, tongue, and lips).

The parent of a four-year, eleven-month old female has requested PROMPT therapy, which includes speech therapy at a frequency of five hours per week and social skills training at a frequency of six hours per week for treatment of her childhood apraxia of speech. Findings: Two physician reviewers found that the patient has been diagnosed with severe apraxia of speech, as well as a mixed expressive/receptive language disorder and impaired communication skills. As a toddler, she was treated at an early childhood partial hospitalization program (PHP), which utilized a comprehensive and multidisciplinary program, including prompts for restructuring oral muscular phonetic targets (PROMPT) techniques. She was discharged from the PHP three years ago with a diagnosis of childhood apraxia of speech. Continued intervention utilizing the PROMPT method was recommended.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with autism spectrum disorder, developmental speech and language disorder, global developmental delay, childhood apraxia of speech (CAS), and mixed expressive-receptive language disorder. The Preschool Language Scale Fifth Edition (PLS-5) placed the patient’s receptive language age equivalency at one year six months, which was in the first percentile. The patient’s expressive language age equivalency was placed as one year eight months, which was in the first percentile. A PLS-5 assessment placed that patient’s receptive language age equivalency at one year 10 months, which was in the first percentile. The patient’s expressive language age equivalency was two years, which was also in the first percentile. The patient’s speech was noted to be less than 50% intelligible.

The patient is a three-year-old male with a history of speech delay without expressive or receptive language delay. Specifically, the speech delay is an articulation disorder with severe oral-motor discoordination and apraxia. The patient also has multiple sound omissions, substitutions and distortions. In addition, the patient has been evaluated by an occupational therapist and found to have feeding, coordination, vestibular and sensory processing difficulties. The patient has oral aversions and has had issues with coughing and vomiting associated with eating. At issue is whether the recommended speech and occupational therapy are medically necessary.The literature submitted in support of the requested speech therapy is primarily professional opinion and is not supported by scientific data.

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 childhood apraxia of speech was denied, the published record says the denial is worth fighting.