Pediatric Verbal Apraxia
XYZ Health Plan denied coverage of speech-language pathology services for Adam, a 5-year-old child diagnosed with verbal apraxia. In denying services, XYZ noted that "the contract has a defined benefit limit of 20 visits per calendar year for speech therapy." Treatment exceeded that limit. This letter encourages XYZ to continue coverage of speech-language pathology services for Adam because standards of practice support more visits per year for the disorder of verbal apraxia.
Adam's speech-language pathology treatment is medically necessary to treat his verbal apraxia, a speech disorder that likely is neurologically based. It impairs his speech production and interferes with his ability to initiate and sequence motor movements for speech. Researchers have identified a gene mutation that appears responsible for pediatric verbal apraxia (Nature, 413, 519-523).
Determining medical necessity takes into consideration whether the service is essential and appropriate to the diagnosis and/or treatment of an illness, injury, or medical condition. Verbal apraxia is a medical condition and a disorder of body function in that speech muscles have limited control. Speech-language services are "essential and appropriate" in treating Adam's verbal apraxia.
Practice standards call for more treatment sessions than 20 visits per calendar year. "Intensive services are needed for the child with apraxia of speech," according to Penelope Hall, an expert in diagnosing and treating this disorder. XYZ would not provide only 10 cancer treatment sessions, when research and standards of care showed that 30 sessions were necessary to achieve the best outcome. Care should not be limited to coverage levels that produce less than desired results.
ASHA joins the family in requesting that additional treatment sessions beyond 20 visits per year be allowed to bring Adam's speech to age level expectations.
Pediatric Verbal Apraxia
I am writing in support of XYZ Health Plan's payment of speech-language pathology services for Adam. XYZ denied payment for speech-language pathology services because benefits cover only the restoration of speech after loss or impairment of a demonstrated, previous ability to speak (see enclosed letters). You indicate in your letter of January 25, that "speech therapy for deficiencies of speech caused by developmental delay is considered to be educational" and, therefore, excluded. Please let me take this opportunity to explain why Adam's speech-language pathology treatment should be covered.
Adam's speech-language pathology treatment is medically necessary to treat his verbal apraxia, a medical condition that impairs speech production. David Jones, M.D., writes in the enclosed report that Adam's "neurological exam has always been abnormal in the past, indicating neurologic damage" as the cause of his impairments. XYZ's coverage guidelines require a demonstration of previous speaking ability. This criteria is unreasonable when applied to infants and young children. It essentially excludes treatments for the youngest of your beneficiaries.
When neurological damage is the cause of speech-language impairment, benefits should be available, including benefits to young children, without the added requirement of demonstrating previous speaking ability for a population that cannot possibly comply. You also indicate that Adam's speech-language needs are due to developmental delay and thus considered educational. Adam's speech-language impairment is neurologically based and is not a developmental delay nor educational in nature. It is treatment for a medical condition.
Additionally, I understand that the family was assured by XYZ that Adam's speech-language treatment would be covered when they were considering switching from ABC Health Plan which previously covered his treatment.
Please reconsider coverage of speech-language pathology services for Adam. This treatment is medically necessary to treat the medical condition of verbal apraxia, which is the result of neurological damage.
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