Speech And Language Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested speech and language therapy for treatment of the enrollee’s autism. Findings: The physician reviewer found that autism is a complex neurological disorder with characteristic deficits in speech and language and social interaction. There are likely a multitude of etiologies, with clinical symptoms being the common denominator. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in children with autism. Typically, young patients on the autistic spectrum disorder (ASD) require interventions in multiple areas, provided using a team approach. Speech and language therapy is one of the modalities that is often indicated. Fundamental to the diagnosis of ASD are deficits in speech and language.

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent has requested authorization and coverage for speech and language therapy. A review of the records indicates the enrollee was diagnosed with speech delay, specifically developmental expressive language disorder after an Early Intervention in-home evaluation. At the time of evaluation, he was not saying any words and was communicating through gestures and vocalizations. At the end of the evaluation, the impression was that the enrollee had a significant delay in his language expression skills. His hearing is normal and his social skills are also normal for age. Speech and language intervention was recommended with the goal of being able to communicate his wants and needs, add 50 new words to his vocabulary and begin to use 2 and 3-word phrases.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s language skills as assessed by the Clinical Evaluation of Language fundamentals-5 were within the typical range of development. An assessment of fluency was also within the typical range of development, although monitoring was suggested. The primary area of concern was speech sound development. Testing that utilized the Goldman Fristoe Test of Articulation-3 noted errors that included the following sounds: /r/; vocalic /r/; /th/, /dz/, as well as some idiosyncratic errors on /t/ and /b/. He also had a rapid rate of speech, which decreased intelligibility. Progress reports documented limited progress in the acquisition of the /r/ and vocalic /r/ sounds, and noted improvement in the production of multisyllabic words /th/ sound and reduction of the rate of speech.

Nature of Statutory Criteria/Case Summary: An enrollee has requested daily outpatient skilled rehabilitation services for treatment of her medical condition. Findings: The physician reviewer found that based on the documentation submitted for review, daily outpatient skilled rehabilitation services provided have not been established as medically necessary. The patient’s functional mobility and self-care were at a level that did not require additional skilled intervention. A home exercise program and outpatient care of a physiatrist were sufficient. The patient did continue to have language deficits.

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 And Language Therapy, then check the rights and deadlines that apply to your plan.