Expressive Speech Delay: when insurers say no, reviewers often say yes

Where the denial was overturned

The parent of a four-year-old male has requested five hours of speech therapy per week and five hours of occupational therapy per week for treatment of his autism. Findings: The physician reviewer found that the in-Plan speech therapist and the non-Plan speech therapist had good concordance in reporting a severe expressive speech delay and essential non-functional language skills. The medical community’s standard of practice for autistic children is to provide both occupational and speech therapy to autistic children. The medical literature supports both occupational therapy and speech therapy in this population.Pfeiffer, et al. reported on an extensive meta-analysis of the literature and concluded that occupational therapy is effective in reducing many of the problematic mannerisms associated with autism.

The parent of a 1-year, 10-month-old male enrollee has requested authorization and coverage for speech therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollee’s expressive speech delay. Findings: The physician reviewer found that in child development, delay in acquisition of speech is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities.

Where the denial was upheld

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollee’s speech delay. Findings: The physician reviewer found that this patient has an identified delay in expressive speech of approximately 25% with normal receptive language abilities, per the Rossetti Infant-Toddler Scale and Developmental Assessment of Young Children. There is no noted delay in play skills or pragmatics. Speech therapy is indicated with any delay greater than 25%. An extensive review of the literature, including a meta-analysis by Law et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman et al. note that treatment for language disorders is predicated primarily on the child’s language profile and level of communication skills.

The patient is a three-year-old male with an expressive speech delay. He has a history of otitis media but there is no documentation of an effusion. Audiology was reportedly within normal limits. Initial speech evaluations were performed by two different providers in June 2004 and December 2004. The evaluations document mild to moderate speech delay. It appears the patient has been receiving speech therapy since February 2005. A request has been made for authorization and coverage for continued speech therapy at a frequency of three times per week. The Health Plan has denied this request on the basis that continued therapy is not medically necessary for treatment of the patient’s condition.In reviewing the submitted documentation, the June 2005 progress report does not demonstrate that progress has been made in this case.

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 speech delay was denied, the published record says the denial is worth fighting.