Delayed Speech denials in California external review

What the reviewers wrote

Where the denial was overturned

The parent of a four-year-old male enrollee has requested for speech therapy for treatment of his delayed speech. Findings: The physician reviewer found that Nelson and colleagues reports that speech and language development is a useful indicator of a child’s overall development and cognitive ability and is related to school success. Additionally, they note that language-delayed children have also shown more behavior problems and impaired psychosocial adjustment. From this detailed account, it is clear that speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties.

The parent of a 20-month-old male enrollee has requested for speech therapy for treatment of the enrollee’s delayed speech. Findings: The physician reviewer found that speech therapy is indicated with any delay greater than 25 % (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is “predicated primarily on the child’s language profile and level of communication skills” (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for speech therapy services. Speech therapy is known to be effective to help children with language impairments develop functional language skills. To determine the need for speech therapy services, a formal evaluation is needed and must be performed by a speech therapist. The evaluation needs to include a patient history, observation of behaviors and formal standardized scoring with a validated tool. Additionally, the patient’s physician needs to provide a referral or prescription for the requested services and a signed plan of care.

The parent of a 22-month-old male enrollee has requested speech therapy for treatment of the enrollee’s delayed speech. Findings: The physician reviewer found that the most recent speech evaluation provided was performed when the patient was 18-months-old. Speech acquisition at this age is quite limited, with the anticipated utilization of approximately 10 words (Simms). With a scattering out to 15 months both in receptive and expressive language, the patient was still at the lower limits for normal speech development, particularly for a male. Thus, speech therapy is not medically necessary for this patient at this time. The article by Buschman, et al. recommends evaluation for late talkers at the age of two, as a substantial number of late talkers will be verbal by this age.

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 delayed speech, then check the rights and deadlines that apply to your plan.