January 22, 2002 Bottom Line

Bottom Line: Getting Health Plans to Pay for Pediatric Verbal Apraxia

A recent e-mail from a speech-language pathologist and parent of a child diagnosed with verbal apraxia highlights the reimbursement problems for this disorder. Wendy Foulke, a member from Pemberville, OH, writes, "We are fighting terribly with our insurance company over this diagnosis of apraxia." The health plan refuses to pay the claim because it is for "educational speech therapy" for a disorder "that will resolve." Other health plans also refuse to pay for this treatment, claiming it is a "developmental" problem, pointing to the often-used term of "developmental apraxia of speech" found in literature.

What can clinicians do to ensure payment for pediatric verbal apraxia? There are four important steps:

  • Educate payers about the nature of this communication disorder and relate the description to coverage language from the health plan policy. The term "apraxia of speech" is used to describe a speech disorder (considered by many to be neurologically based) that interferes with a child's ability to initiate and sequence motor movements for speech. The child has limited control of speech muscles. It is an oral-motor speech disorder characterized by the loss of ability to consistently position the articulators for speech. Unintelligible speech is the result.
  • When filing or appealing claims, indicate that speech-language pathology treatment is medically necessary because this disorder is a medical condition consistent with the definition of disease and illness (which policy language typically covers) and that it is a disorder of body function. Include any neurological exams that show abnormal characteristics. Point out that the coverage requirement that one must first possess an ability and then lose it does not allow for the medically related needs of infants and young children.
  • Make clear that verbal apraxia is not a developmental delay. A child will not outgrow this disorder. Developmental delay of speech is when a child follows a typical path of speech development, but at a slower than normal rate. Children with verbal apraxia generally have a wide gap between their receptive and expressive language abilities, with receptive abilities normal and expressive abilities seriously deficient. Use of the term "developmental" in reference to verbal apraxia is used only to denote that the apraxia is present in a pediatric patient, rather than an adult patient who becomes apraxic as a result of a brain injury. The term "developmental" should be reconsidered for its appropriateness as a descriptor for this disorder, particularly with attention to reimbursement.
  • Describe the treatment plan and expected results. Children with verbal apraxia respond best to motor treatment that is focused on the control of speech movements. Carefully structured treatment programs that combine muscle movement, speech sound production, and sometimes even work on grammar and expressive language skills seem to get the best results. Intensive therapy should begin as soon as the disorder is identified and should be consistent and frequent. Without professional speech-language and oral-motor treatment, children with verbal apraxia will not develop normal speech. With treatment, prognosis is good.

A recent scientific finding may shed light on the cause of pediatric verbal apraxia. British neurogeneticists at the Wellcome Trust Center for Human Genetics at the University of Oxford say they have identified a gene mutation that appears to be responsible for pediatric verbal apraxia (Lai, C., Fisher, S., Hurst, J., Vargha-Khadem, F., & Monaco, A. [2001]. A gene is mutated in a severe speech and language disorder. Nature, 413, 519–523). The researchers cannot tell the exact physiology of the mutation, but studies suggest that the basal ganglia, a region of the brain that controls movement, may be slightly different in individuals with verbal apraxia. Further research is needed to provide clarification in diagnosing and treating verbal apraxia.

And what about Foulke's appeal? The health plan reversed its decision to deny the claim, allowing three sessions weekly and recognizing the likely long-term nature of treatment. Why the reversal? Foulke says she was "relentless," using her knowledge as an SLP and her steadfastness as a parent to argue the neurological basis of the disorder and the need for frequent and intense treatment.

For more information about reimbursement and pediatric verbal apraxia, contact Janet McCarty through the Action Center at 800-498-2071, ext. 4194, or by e-mail at jmccarty@asha.org, or check out Apraxia-Kids.org.


  

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