Mixed Receptive-expressive Language Disorder: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for three 30-minute speech therapy sessions weekly, a single one-hour physical therapy session weekly, and a single one-hour occupational therapy session weekly. The records document that this patient has been diagnosed with autism spectrum disorder, mixed receptive-expressive language disorder, and developmental coordination disorder. The patient has a mutation in the JMJD1C gene, which has been described as being associated with autism spectrum disorder and developmental delay. The patient’s receptive, expressive, and pragmatic language skills are severely delayed. In addition, the patient has a 50% delay in his fine motor skills. The provider has recommended treatment with applied behavior analysis (ABA), occupational, physical, and speech therapies.

Findings: The physician reviewer found that The patient’s parent has requested reimbursement and prospective authorization and coverage for speech therapy sessions provided three times a week in one-hour sessions. On review of the available documentation, the speech therapy sessions provided three times a week in one-hour sessions were and are medically necessary for the treatment of this patient. The patient has a history of autism spectrum disorder (ASD), mixed receptive/expressive language disorder, and childhood apraxia of speech. The patient’s provider describes that the patient is making slow but definite progress with speech therapy.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for two additional speech therapy visits per week (for a total of three session per week). Findings: The physician reviewer found that a meta-analysis of 25 studies on speech and language therapy interventions for children with primary speech and language delay or disorder, Law and colleagues report that overall, there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties, while noting that the evidence for expressive syntax difficulties is more mixed. The authors did not address dosing of therapy, and further noted that there is a need for further research to investigate interventions for receptive language difficulties. The U.S.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for speech therapy. In this case, the patient has a diagnosis of autism spectrum disorder (ASD) and severe mixed receptive-expressive language disorder. The American Academy of Pediatrics (AAP) guidelines on the identification, evaluation, and management of children with autism spectrum disorder notes that all children with ASD should have documentation of specific coexisting speech and language diagnoses so that appropriate intervention might be provided. The AAP further notes that speech-language therapy is the most commonly identified intervention provided for children with ASD.

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 mixed receptive-expressive language disorder was denied, the published record says the denial is worth fighting.