Expressive Language Disorder denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for authorization and coverage for a Tobii Dynavox I-13 Speech Device (CPT E2510), an eye gaze interaction accessory (CPT E2512), and a mount (CPT E2599).Graziola and colleagues have explained that children with GNAO1 mutations usually need to use a wheelchair and have numerous motor constraints, including dystonic movements and postures and hypotonia, making cognitive assessment difficult. This contributes to their disability, resulting in a high level of frustration for both caregivers and patients. Graziola and colleagues evaluated six children with GNAO1 mutations and found that these children showed variable degrees of communicative intent through intentionally directed gaze.

The parent of a four-year-old male enrollee has requested authorization and coverage for speech therapy for treatment of the enrollee’s severe apraxia of speech and expressive language disorder. Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patient’s case. As reported by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a child’s overall development and cognitive ability and is related to school success. The authors reported that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. According to Law and colleagues, approximately 6% of children have speech and language difficulties.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of a six-year-old male enrollee has requested authorization and coverage for individual and group speech therapy for treatment of the enrollee’s expressive language disorder. Findings: The physician reviewer found that the request for individual and group speech therapy is not medically necessary for this patient. According to colleagues there is “some evidence that social skills groups can improve social competence for some children and adolescents with ASD” although the study underscores that “more research is needed to draw more robust conclusions, especially with respect to improvements in quality of life.” Another systematic review on the subject indicates that “Social skills interventions presently appear modestly effective for youth with ASD, but may not generalize to school settings or self-reported social behavior”.

The patient is a seven-year-old female with a history of expressive/receptive language delays and abnormal auditory processing. In March, 2006, her pediatrician documented additional symptoms, which may place the patient on the autism spectrum. The pediatrician has recommended, “further psycho-educational testing to delineate the patient’s developmental disabilities.” The patient has been receiving speech therapy since September 2005. The submitted speech therapy evaluations indicate the patient has met 5 of 7 goals and has made progress toward the other goals. At issue is whether speech therapy is medically necessary for treatment of the patient’s condition.The patient’s diagnoses of expressive/receptive language disorder and abnormal auditory processing disorder have not been documented to have a medical basis and are generally considered educational in nature.

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