Expressive Language Delay denials in California external review

What the reviewers wrote

Where the denial was overturned

The parent of a 3-year-old male enrollee has requested speech therapy (2 hours per week) and occupational therapy (2 hours per week) for treatment of the enrollee’s autism. Findings: The physician reviewer found that speech therapy is a medically necessary intervention for this patient with autism given his history of expressive and receptive language delays with socialization deficits. In the relevant medical literature, Stone and Yoder evaluated 34 children with autism at 2 years of age with 2-year follow-up to examine factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. The authors concluded that the patients with significant speech and language intervention improved in their language development.

The parent of a 3-year-old male enrollee has requested speech therapy (2 hours per week) and occupational therapy (2 hours per week) for treatment of the enrollee’s autism. Findings: The physician reviewer found that speech therapy is medically necessary for this young patient with autism and a history of expressive and receptive language delays with socialization deficits. In the relevant medical literature, Stone and Yoder evaluated 34 children with autism at 2 years of age with 2-year follow-up to examine factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. The authors concluded that the patients with significant speech and language intervention improved in their language development.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent is requesting authorization and coverage for speech therapy services twice per week. The enrollee has developmental delay, speech delay, expressive language delay, and dyslexia. He is followed by a developmental-behavioral pediatrician and has been receiving speech therapy services since he was two and a half years old. The physician recommended speech therapy services for 50 minutes per session, at a frequency of two times per week. The enrollee’s mother reports her son is still showing articulation problems and problems composing sentences. She reports he has problems associating with other children because of his speech problems. Records show the enrollee performed poorly on standardized testing before starting speech therapy. This enrollee has received speech therapy for seven years.

The patient is a six-year-old male with a history of febrile seizures. The patient also has developmental and social delays and has been diagnosed with expressive language delay, oral motor difficulties, mild phonological disorder, and moderate developmental apraxia of speech. The patient underwent a developmental evaluation in 2002, which reflected multiple components of developmental delay with both sensory issues and fine and gross motor issues. The patient had many of the components of pervasive developmental disorder, but did not meet the criteria for pervasive developmental disorder. Subsequently, the patient was diagnosed with the above language disorder by his speech therapist. It appears the patient has received approximately eight months of speech therapy. A request has been made for additional speech therapy.

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 expressive language delay, then check the rights and deadlines that apply to your plan.