Speech Delay denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for speech therapy (one 50-minute visit weekly). The American Speech-Language-Hearing Association (ASHA) notes that the goal of intervention with augmentative and alternative communication (AAC) is to maximize the efficiency and effectiveness of communication for individuals who are unable to communicate via verbal speech, with intervention taking place in a naturalistic environment in order to promote generalization and functional use whenever possible. ASHA notes that potential areas of focus for treatment include using AAC to improve functional communication, increase language and literacy skills, improve speech production and comprehensibility with the use of multiple modalities, decrease challenging behaviors, and improve social communication.

The parent of a four-year-old female enrollee has requested speech therapy for treatment of the enrollee’s speech delay. Findings: The physician reviewer found that language development is one of the most significant processes of early childhood development. Developmental delay often accompanies delayed speech development. Speech development is an important predictor for later problems, such issues with reading and spelling, among other learning difficulties. Different researchers describe children with delayed speech development as being highly at risk of other cognitive, social-emotional, and school-related problems. In the medical literature, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for speech therapy (one one-hour session weekly). The submitted documentation does not support the medical necessity of the requested services. Current medical literature generally supports a 1.5 standard deviation deficit that marks a moderate degree of speech delay to qualify for speech therapy services. Medical literature notes that an individual needs to exhibit a functional deficit in order to be considered for speech therapy. In this case, the speech therapist noted that the patient is at the 39th percentile for his age in language skills and has functional communication appropriate for his age. The measured score is within one standard deviation of the mean and is thus in the normal range.

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent is requesting authorization and coverage for speech therapy services twice per week. The enrollee has developmental delay, speech delay, expressive language delay, and dyslexia. He is followed by a developmental-behavioral pediatrician and has been receiving speech therapy services since he was two and a half years old. The physician recommended speech therapy services for 50 minutes per session, at a frequency of two times per week. The enrollee’s mother reports her son is still showing articulation problems and problems composing sentences. She reports he has problems associating with other children because of his speech problems. Records show the enrollee performed poorly on standardized testing before starting speech therapy. This enrollee has received speech therapy for seven years.

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