Stuttering: when insurers say no, reviewers often say yes

Where the denial was overturned

The parent of an 11-year-old male enrollee has requested speech therapy for treatment of the enrollee’s stuttering disorder. Findings: The physician reviewer found that despite years of community and school based speech therapy the patient continues to stutter. The patient’s speech therapist reported a 70% speech dsyfluency and the child psychiatrist assessed the patient as a stutterer. Intensive speech therapy is necessary to prevent stuttering from becoming a lifelong disability. Based on an extensive survey of children in North Carolina, spontaneous remission from stuttering is the exception not the rule, and that the chance of recovery from stuttering diminishes with age (Kalinowski, et al). Without intensive speech therapy this nearly 12 year-old patient has little chance of improvement from stuttering.

The parent of a four-year-old male enrollee has requested speech therapy for the treatment of the enrollee’s speech disorder. Findings: The physician reviewer found that this patient is a young preschool-aged child with neuro-oral-muscular dis-coordination resulting in a severe stuttering disorder. Some theorists consider stuttering to be the result of subtle neuron-physical dysfunctions resulting in disruption of the precision needed to produce speech. Stuttering, or speech dysfluency may be divided into developmental stuttering, neurogenic stuttering that results from neurological problems, and psychogenic stuttering that occurs following psychological trauma. Up to 80% of children who experience developmental dysfluency, or mild pathologic dysfluency, recover spontaneously. However, a certain number of children deteriorate, developing severe dysfluency.

Where the denial was upheld

A 37-year-old male enrollee has requested for the Fluency Master for treatment of his speech pathology. Findings: Three physician reviewers found that the Fluency Master is an electronic device that uses a technology called altered auditory feedback (AAF). According to the manufacturer, the device fosters “better hearing of the natural vocal tone associated with speaking.” In 2002, the National Stuttering Association conducted a survey of its membership. One of the questions asked was about experiences with an AAF device, including the Fluency Master. 38% of the respondents categorized their experience with this type of device as not at all successful, 44% said their experience was somewhat successful, and 18% reported their experience was very successful. Bothe, et al.

A 50-year-old male enrollee has requested speech therapy for treatment of his stuttering. Findings: The physician reviewer found that a review of the scientific literature reveals a study by Koedoot and colleagues which states, “moderate to severe stuttering has a negative impact on overall quality of life.” In regards to treatment, a review by Blomgren states, “although it is presented that a comprehensive approach to stuttering treatment will provide the best results, no single approach to stuttering treatment can claim universal success with all adults who stutter.” In the case of this patient, he reportedly has stuttering however there is no description of the severity, duration, onset or prior treatment, if any.

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 stuttering was denied, the published record says the denial is worth fighting.