Speech Problems denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) three sessions per week of physical therapy and (2) three sessions per week of speech therapy. Functional impairments due to acquired brain insults such as stroke can be severe to profound. Belagaje notes that rehabilitation is an important aspect of the continuum of care in strokes, and that successful rehabilitation involves understanding the natural history of stroke recovery and a multidisciplinary approach to identify and treat common poststroke sequelae. Kubis notes that patients may improve spontaneously within the first three months and then more slowly in the coming year.

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.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued care at a skilled nursing facility (SNF), including continued physical therapy and occupational therapy. Functional impairments due to acquired brain insults such as stroke can be severe to profound. While functional recovery may be amenable to natural recovery processes and rehabilitative measures, the extent of initial injury is a major determinant of functional outcomes as it defines the residual neuronal reservoir that is capable of engaging in recovery (Alawieh, et al.). Most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke such as in the first 30 days, and gains are slower to come in the subsequent stages (Kubis).

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acute rehabilitation for speech therapy. The submitted documentation does not support the medical necessity of the requested acute rehabilitation for speech therapy. In this case, the patient sustained a stroke resulting in global aphasia. He has recovered functionally from a physical standpoint and is able to return to the community with assistance from caregivers and community-based speech, physical, and occupational therapies. There is a lack of substantial improvement in outcomes that would be expected with intensive speech therapy provided in an inpatient setting over community-based therapy, including via telerehabilitation options.

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