Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Speech Therapy.

The insurer denied Speech Therapy.
The denial is upheld.

This patient is a male with a diagnosis of mixed receptive-expressive language disorder. The patient initially received speech therapy services which were interrupted due to the coronavirus 2019 (COVID-19) pandemic. During this time the patient showed regression of learned skills; thus, resumption of speech therapy was requested.
Comprehensive evaluation was provided. Standardized scales were used to evaluate receptive and expressive language skills. Receptive language index standard score was 14% indicating a mild delay in receptive language skills. Expressive language index standard score was 23% indicating an average score and skills that are within functional limits. Overall, the patient's communication ability was deemed a mild receptive-expressive language delay and once weekly speech therapy was recommended to address receptive language skills and executive functioning skills.

Academic records show struggling grades in reading comprehension, correlating with evaluation findings. A letter indicated the patient had received outpatient speech therapy for 30 minutes/session once weekly.
At issue is Speech Therapy for medical necessity.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Speech Therapy is not medically necessary for this patient.

According to the medical documentation provided, there is no documentation to support the medical necessity of ongoing speech therapy services for this patient. This male presented with speech and language concerns. Results of a comprehensive evaluation, now a year out of date, indicate composite receptive language score of mild delay at the 14th percentile and expressive language or normal functioning at the 23rd percentile. Although the speech and language provider provided a written summary of goals, they did not include individual session notes showing interval progress towards stated goals. Additionally, it is unclear whether specific speech and language services would be most beneficial to this child, versus academic supports and services.
Therefore, the requested health service/treatment of Speech Therapy is not medically necessary.