Speech And Language Delay: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent is requesting authorization and coverage for three (3) sessions per week of speech therapy co-treatment with occupational therapy, one (1) session per week of speech therapy co-treatment with a behavior technician and one (1) session per month of speech therapy co-treatment with a BCBA. The enrollee has autistic disorder and speech/language delay and receives speech therapy (ST) and occupational therapy (OT). Concerns are related to motor planning/coordination skills and sensory processing differences affecting activities of daily living (ADL) independence. The enrollee is showing measurable gains by his continued progress with goal areas and increased independence in self-care skills. The ST re-evaluation report indicates the enrollee started therapy with two times per week for 30 minutes.

The parent of a two-year-old female enrollee has requested one hour per week of speech therapy and one hour per week of sensory integration focused occupational therapy for treatment of the enrollee’s autism. Findings: The physician reviewer found that with regard to the requested speech therapy, Eikeseth noted that the goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have autism. On average, the young patients who received the behavioral treatment gained 17 IQ points, 13 points in language comprehension, and 23 points in expressive language and 11 points in adaptive behaviors. In comparison, the eclectic treatment group obtained an average of +4 points in IQ, and made no further gains.

Where the denial was upheld

The patient is a five-year-old male with a diagnosis of speech and language delay (expressive and receptive). He also has a diagnosis of auditory processing disorder. He has been receiving speech therapy since July 2003. The record provided for review includes an evaluation from January 2005 and daily progress notes from September 2004 through May 2005. The Health Plan has denied coverage for speech therapy provided from January 2005 through May 2005 based upon a determination that it was not medically necessary.The January progress report indicates the patient was meeting all goals at that time. However, the daily notes only document the treatment that was provided during the session and do not address functional goals. Additionally, the therapist does not perform standardized testing to show progress toward specific goals.

The patient is a seven-year-old male with multiple diagnoses relating to cognition with a primary diagnosis of attention deficit hyperactivity disorder (ADHD). The patient has been seen by a speech therapist who has documented a significant speech and cognitive delay. Additionally, neuropsychological testing has been performed. The patient’s neuropsychologist recommended ongoing speech and language therapy. The Health Plan indicates that continued speech therapy is not medically indicated.Based upon review of the pre-and post-speech therapy documentation, it is apparent the patient has regressed is some areas despite therapy. In addition, there is not sufficient literature evaluating speech therapy as a primary treatment for ADHD. Typically, medications are used as the primary treatment for this disorder with speech therapy used as an adjunctive 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 speech and language delay was denied, the published record says the denial is worth fighting.