Receptive Language Delay: when insurers say no, reviewers often say yes

Where the denial was overturned

The parent of a 3-year-old male enrollee has requested speech therapy (2 hours per week) and occupational therapy (2 hours per week) for treatment of the enrollee’s autism. Findings: The physician reviewer found that speech therapy is a medically necessary intervention for this patient with autism given his history of expressive and receptive language delays with socialization deficits. In the relevant medical literature, Stone and Yoder evaluated 34 children with autism at 2 years of age with 2-year follow-up to examine factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. The authors concluded that the patients with significant speech and language intervention improved in their language development.

The parent of a 3-year-old male enrollee has requested speech therapy (2 hours per week) and occupational therapy (2 hours per week) for treatment of the enrollee’s autism. Findings: The physician reviewer found that speech therapy is medically necessary for this young patient with autism and a history of expressive and receptive language delays with socialization deficits. In the relevant medical literature, Stone and Yoder evaluated 34 children with autism at 2 years of age with 2-year follow-up to examine factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. The authors concluded that the patients with significant speech and language intervention improved in their language development.

Where the denial was upheld

This patient is a three-year-old male with a history of speech and language delays. His hearing has been tested and was determined to be normal. The patient has been evaluated by two speech therapists and found to have mild receptive and moderate expressive language delays. There are no other developmental delays documented in the record provided for review. The patient has a history of behavioral issues which are believed to be related to his speech difficulties. His speech therapist noted good eye contact and cooperation during the evaluation. The therapist suggested that the patient’s multiple ear infections are the cause of the speech delays, but there is no documentation of treatment for ear infections in the records from July 2005 through June 2006. The patient’s parent has requested authorization for speech therapy.

The parent of a two-year-old female enrollee has requested three hours of speech therapy per week for treatment of the enrollee’s autism and expressive/receptive language delay. Findings: The physician reviewer found that there is extensive medical literature supporting the value of speech therapy for improvement of pragmatic speech in autistic children. At issue in this case is whether individual speech therapy at a frequency of three hours per week is medically indicated over individual speech therapy at a frequency of two hours per week, which has been authorized by the Health Plan. There are few studies available regarding the appropriate intensity, duration, and frequency of therapy for speech impaired children with autism. In this case, the patient is currently receiving two hours of speech therapy per week, coupled with 24 hours of ABA therapy plus occupational therapy.

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