It's frustrating for children with childhood apraxia of speech to say what they want to say. It is additionally frustrating for families when health plans deny coverage for speech-language treatment for the disorder. What makes for a successful appeal to payers? Here are the points to make in an appeal:
- CAS is a motor speech disorder that is neurologically based.
- A child with CAS has limited control of muscles and problems
saying sounds, syllables and words. The difficulty is not due to muscle
weakness or paralysis. The child's brain has difficulty planning the movements of the body parts needed for speech.
- CAS is not a developmental delay. It is an issue of health
and normal physiological function.
- Treatment for CAS is medically necessary because the
disorder is a medical condition consistent with the definition of disease and
illness. It is a disorder of body function. (Include any neurological exams
that show abnormal characteristics.)
- Scientific findings shed light on the cause of CAS. British
neurogeneticists identified a gene mutation that appears responsible for CAS,
or verbal apraxia (Nature, 413, 519–523; 2001). Studies suggest that the basal
ganglia, brain regions that control movement, may be different for those with
- The appropriate ICD-9 diagnostic code (International
Classification of Diseases, ninth edition) for CAS is 784.69 (Other symbolic
dysfunction; acalculia, agnosia, agraphia, apraxia).
- Provide supporting evidence of the disorder (for example, a
specific childhood apraxia of speech test).
Additional support for insurance coverage comes from a 2003 ruling by a Michigan insurance commissioner, which concluded that the diagnosis
of childhood apraxia of speech can be viewed as both developmental and
neurological. The ruling stated that developmental and neurological issues are
not mutually exclusive, and both may exist in relation to a diagnosis.
In that case, Blue Cross Blue Shield of Michigan denied
speech-language treatment for a child diagnosed with expressive language
impairment and CAS. Even though BCBSM admitted that speech-language treatment
was a covered benefit under the insurance contract, it argued that the contract
specifically excluded coverage for speech and language conditions that were
"developmental." BCBSM claimed that the child's condition was developmental and, therefore, not covered. BCBSM further claimed that the child was being treated for stuttering and for articulation errors—both of which, the insurance carrier argued, were developmental.
An independent review organization stated that speech
disorders in children are often both developmental and organic and that one
does not automatically exclude the other. The IRO found that although the
child's speech issues were longstanding, developmental and possibly congenital, the impairment was also neurological, thus organic. The IRO also stated that the child's apraxia of speech and stuttering may have neuropathological correlates. The commissioner then ruled that the child's condition was not strictly developmental in nature and, therefore, the speech-language treatment was a covered service.
ASHA has a CAS appeal packet that contains the information
outlined in this article and that can be adapted and personalized. ASHA members
who have received and want to appeal a CAS denial can request the packet from
Janet McCarty, firstname.lastname@example.org.