Expressive Language Impairment: when insurers say no, reviewers often say yes

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 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 expressive language impairment was denied, the published record says the denial is worth fighting.