Expressive Language Impairment denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for speech therapy services. The available records document that this patient has severe expressive, receptive and pragmatic language impairment due to his autism spectrum disorder. Although the patient scored below the first percentile for expressive and receptive language on the Oral and Written Language Scales Second Edition (OWLS-2), his speech therapy reports indicate progressive improvement in intelligibility of speech. This is despite the patient missing several months of speech therapy and having predominantly telehealth sessions during the pandemic. The provider noted that the patient has met several goals, and the patient has shown progress towards other goals.

The parent of a two-year-old male enrollee has requested speech therapy for one hour, two times per week for treatment of the enrollee’s moderate expressive language impairment. Findings: The physician reviewer found that as noted 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 noted 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. Speech and language delay must be taken very seriously in young children, because the long-term consequences may be substantial. As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.

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