Group Speech Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

The parent of a two-year-old male enrollee has requested speech therapy in a group of two or more for treatment of the enrollee’s expressive and receptive language disorder. Findings: The physician reviewer found that language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patient’s voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patient’s overall development and can be tracked using typical milestone markers. While most young patient’s difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school achievement.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested group speech therapy services and social skills for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. Group speech therapy services and social skills are indicated to address the social skills deficits with the patient’s peers. The patient presents with good expressive and receptive language skills. However, standardized tests do not pick up the problems with social communication that is seen in a child with autism spectrum disorder. According to the American Academy of Pediatrics “People with ASDs have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of a four-year-old male enrollee has requested reimbursement and prospective authorization and coverage for social skills group therapy and group speech therapy services. Findings: The physician reviewer found that based on the available documentation, the social skills group therapy and group speech therapy services provided were not and are not medically necessary for treatment of this patient’s medical condition. The National Autism Center highlights ABA therapy as the most effective evidence-based treatment for autism. In this case, the patient is currently accessing medically necessary treatment in the form of ABA therapy, which has led to a decrease in overall autism symptoms. While the patient still has specific areas of concern, his ABA provider has outlined goals to focus on the patient’s specific deficits.

The patient’s parent has requested authorization and coverage for group speech therapy for an hour, once a week and after school hours. Researchers recommend that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism. The authors noted that further development of therapy plans and interventions targeting pragmatics is lacking. At present, per the description by the patient’s speech provider of his behavior, the requested group speech therapy is not medically necessary. While he should benefit from continued individual speech therapy, his behavior is not conducive to him benefitting from group speech therapy. The patient’s behavior is also likely to be disruptive to other children in the group speech therapy session.

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 Group Speech Therapy, then check the rights and deadlines that apply to your plan.