Speech Therapy denials in California external review
In the California DMHC record, independent physician reviewers decided 939 published external-review cases involving Speech Therapyand overturned the plan’s denial in 73.7%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Autism Spectrum Disorder | 344 | 75.9% |
| Speech Delay | 122 | 80.3% |
| Expressive Language Delay | 69 | 88.4% |
| Articulation Disorder | 37 | 59.5% |
| Down Syndrome | 25 | 92% |
| Receptive Language Delay | 24 | 87.5% |
| Expressive Speech Delay | 23 | 78.3% |
| Expressive Language Disorder | 22 | 68.2% |
| Speech And Language Delay | 22 | 81.8% |
| Childhood Apraxia Of Speech | 20 | 60% |
| Language Delay | 20 | 65% |
| Autism | 17 | 47.1% |
| Mixed Receptive-expressive Language Disorder | 15 | 46.7% |
| Global Developmental Delay | 15 | 80% |
| Expressive Language Impairment | 14 | 100% |
| Delayed Speech | 13 | 69.2% |
| Apraxia Of Speech | 13 | 92.3% |
| Stuttering | 13 | 61.5% |
| Receptive And Expressive Language Delay | 12 | 83.3% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 928 | 73.4% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 11 | 100% |
What the reviewers wrote
Where the denial was overturned
Findings: The physician reviewer found that The patient has requested authorization and coverage for full day speech, physical, and occupational therapies performed for up to four hours per day, five days per week. Current medical literature supports the use of rehabilitation in the context of traumatic brain injury (TBI). Researchers conclude regarding the effects of physical therapy interventions on balance impairments in individuals with TBI, “The evidence about the effects of the physical therapy interventions in improving the balance ability post-TBI was limited.
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for (1) speech therapy services: one hour five times a week and (2) occupational therapy services: two hours three times a week. The submitted documentation supports the medical necessity of a portion of the requested services. The American Academy of Pediatrics guidelines on the identification, evaluation, and management of children with autism spectrum disorder (ASD) describes delayed language as an early concern for many children who are later diagnosed with ASD, and that the communication symptoms included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for ASD reflect core deficits in social communication and interaction including failure of back-and-forth communication, deficits in nonverbal communication such as eye gaze and use of g…
Where the denial was upheld
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for mental health group therapy services focused on attention-deficit/hyperactivity disorder (ADHD) and speech therapy services. The Early Childhood Service Intensity Instrument (ECSII) provides reliable and valid comprehensive guidance in developing treatment or care plans and monitoring progress over time for children ages birth through five years with behavioral health concerns. Using ECSII, providers score patients on a scale of 1-5 in six domains: (1) degree of safety; (2) child-caregiver relationships; (3) caregiving environment (strengths and stressors); (4) functional/developmental status; (5) impact of the child’s medical, developmental, or emotional-behavioral problems; and (6) services profile.
Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for two additional speech therapy sessions per week (for a total of five speech therapy sessions per week).Medical literature shows that delayed language is an early concern for many children who are later diagnosed with autism spectrum disorder (ASD). The authors state that speech-language therapy is the most commonly identified intervention provided for children with ASD. The guidelines do not specify an optimal intensity/dosage of speech therapy. In another study, researchers reviewed a total of 233 children with language impairment on the caseloads of 73 speech-language pathologists (SLPs) and concluded that more intensive language treatment, measured as time, is not necessarily associated with better treatment outcomes.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Therapy, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY