Language Delay denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that the parent of a patient has requested reimbursement and prospective authorization and coverage for speech therapy services. In this case, the patient has language delays. Speech therapy is known to be effective to help children with language impairments develop language skills. Speech therapy is known to be effective to help children with language impairments develop functional language skills. To determine the need for speech therapy services, a formal evaluation is needed and must be performed by a speech therapist. The evaluation needs to include a history, observation of behaviors and formal standardized scoring with a validated tool. To be in accordance with standards of care, patients need pre-linguistic skills to benefit from speech therapy services. In this case, the patient underwent evaluation by a speech therapist.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested speech therapy at the frequency of 3-4 times per month for treatment of the enrollee’s autism spectrum disorder and reduced receptive, expressive and pragmatic language skills. The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. Bitterman and colleagues examined the experiences of preschoolers with autism spectrum disorders (ASDs). The authors found that 86% of preschoolers with ASDs were receiving direct speech therapy in the preschool years. In addition, according to Myers and colleagues “People with ASDs have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for speech therapy (two one-hour sessions per week) and/or occupational therapy (two one-hour sessions per week). Current medical literature supports the use of speech and occupational therapy treatments for children with autism. Researchers note that a commonly delivered dose of speech therapy is once a week. In this case, the patient has autism, with known language delays and behavioral concerns. The records noted that the patient underwent a speech therapy evaluation for habilitative treatment of deficiencies associated with autism spectrum disorder. The provider has recommended one session per week, as supported by current medical literature.

Nature of Statutory Criteria/Case Summary: The parents of the patient requested authorization and coverage for speech therapy servicesSpeech therapy (ST) is known to be effective in assisting children with language impairments to develop functional language skills. In order to determine the need for ST services, a formal evaluation is needed and must be performed by a speech therapist. The evaluation needs to include a history, observation of behaviors, and formal standardized scoring with a validated tool. A review of medical literature indicates that patients with autism need pre-linguistic skills to benefit from ST services. In this case, a review of the record establishes that the patient has language delays. The patient underwent evaluation by a speech therapist whose opinion was that the patient would not benefit from therapies due to not having pre-linguistic skills.

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