Receptive And Expressive Language Delay denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with receptive and expressive language delays. The records noted that the patient does not have any meaningful words. She waved and clapped appropriately. The provider noted that speech therapy was not recommended due to the patient’s limited ability to participate in therapy in a one-on-one clinical setting. The patient’s parent has requested coverage for speech therapy. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether the requested speech therapy is medically necessary for treatment of the patient’s medical condition. The patient was described as shaking her head for “no” and using symbolic gestures. She babbled, waved and clapped appropriately.

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy, at a frequency of two times per week for treatment of the enrollee’s receptive and expressive language delay. Findings: The physician reviewer found that the current medical evidence supports the requested therapy in this patient’s case. Per 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 seriously in young children, because the long-term consequences may be substantial.

Where the denial was upheld

This patient is a 25-month-old female with a history of global developmental delay, esotropia, ptosis, hyperopia, and hypotonia. She is status post a strabismus surgery and surgery to correct the ptosis. She wears glasses. She also has severe receptive and expressive language delays. The patient has been receiving speech therapy since April 2006. At issue is whether speech therapy is medically necessary for the patient’s developmental delays.Review of the relevant literature reveals no evidence to support that the patient’s vision issues are or can be a direct cause of speech delay. Rather, it appears the speech delay is part of a constellation of deficits associated with global developmental delay.

This patient is a five-year-old male with a diagnosis of autism accompanied by receptive and expressive language delays. He received speech therapy and auditory processing therapy from April 2005 through November 2005. The patient’s parent has requested reimbursement for the cost of the auditory processing therapy. The Health Plan denied the request based on a determination that the therapy was not medically necessary for treatment of the patient’s receptive and expressive language delays.I have reviewed the available literature including a Cochrane review of auditory integration training (AIT). There is no evidence of functional benefit with AIT and the available data does not support the application of the therapy.

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