PEDIATRIC VERBAL APRAXIA
INFORMATION PACKET FOR CONSUMERS AND CLINICIANS
Contents:
- ASHA Letter to Support Health Plan Payment for SLP Services for Treatment of Pediatric Verbal Apraxia (you may submit this to the health plan as-is)
- Sample Appeal Letters to Support Health Plan Payment for SLP Services for Treatment of Pediatric Verbal Apraxia
- ASHA Leader Articles on Insurance Coverage of Pediatric Verbal Apraxia
- Independent Review of BCBS of MI Denial of SLP Services for Treatment of Pediatric Verbal Apraxia
- Let’s Talk: Verbal Apraxia in Children
This letter supports health plan payment for speech-language pathology services for children being treated for childhood verbal apraxia. Speech-language Services are medically necessary to treat verbal apraxia, a medical condition that impairs speech function. It is a speech disorder that is neurologically based and affects a child’s ability to initiate and sequence motor movements for speech. The child has limited control of speech muscles.
Recent scientific findings shed light on the cause of pediatric verbal apraxia. British neurogeneticists at the University of Oxford have identified a gene mutation that appears responsible for pediatric verbal apraxia (Nature, 413, 519-523; 2001). Studies suggest that the basal ganglia, a region of the brain that controls movement, may be slightly different in individuals with verbal apraxia.
Verbal apraxia is not a developmental delay and a child will not outgrow this disorder.It is not an educational issue, but rather an issue of health and normal physiological function. Developmental delay describes a slower than normal rate of development, but verbal apraxia is a disorder.
A health plan’s coverage guidelines may require demonstration of previous speaking ability. However, this criteria is unreasonable when applied to young children. It essentially excludes treatment for the youngest of beneficiaries. When the cause of speech-language impairment is neurologically based, 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.
Speech-language treatment for childhood verbal apraxia meets health plan coverage guidelines. The services are medically necessary to treat the physiologically-based impairment of childhood verbal apraxia of speech.
Sincerely,
Janet McCarty
American Speech-Language-Hearing Association
Private Health Plans Advisor
444 NORTH CAPITOL STREET, N.W. 2200 RESEARCH BLVD
SUITE 715ROCKVILLE, MD 20850-3289
WASHINGTON, DC 20001301-296-5700 VOICE or TTY
FAX 202-624-5955 301-296-8577
Appeal Letter: Pediatric Verbal Apraxia
April 12, 2007
XYZ Health Plan
500 Main Street, Suite 101
Washington, DC 20011
Re: Adam Wilson
Member ID#: 321654789
Member Name: Mary Wilson
Group Name: VWXY
Group ID#: 2500
Dear Claims Department:
I am writing in support of payment by XYZ Health Plan for speech-language pathology services for Adam Wilson. XYZ denied payment for such 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.
Sincerely,
Jane A. Smith, PhD, CCC-SLP
Appeal Letter: Pediatric Verbal Apraxia Extension of Services
April 12, 2007
XYZ Health Plan
500 Main Street, Suite 101
Washington, DC 20011
Re: Adam Wilson
Member ID#: 321654789
Member Name: Mary Wilson
Group Name: VWXY
Group ID#: 2500
Dear Claims Department:
On (add date),XYZ Health Plan denied coverage of speech-language pathology services for Adam Wilson, 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." Adam’s 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).
Determination of medical necessity considers 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.
I am requesting that additional treatment sessions beyond 20 visits per year be allowed to bring Adam's speech to age level expectations.
Sincerely,
Jane A. Smith, PhD, CCC-SLP
Additional sample letters can be found online at
Getting Health Plans to Pay for Pediatric Verbal Apraxia
A recent email 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 ActionCenter at 800-498-2071, ext. 4194, or by email at , or check out Apraxia-Kids.org .
Available online at:
Michigan Insurer Rules on Childhood Apraxia of Speech
cite as:
Gretz, S., & Bauer, K. (2004, May 25). Michigan Insurer Rules on Childhood Apraxia of Speech. The ASHA Leader, pp. 1, 28.
by Sharon Gretz and Kathy Bauer
A 2003 ruling by an insurance commissioner in Michigan that the diagnosis of childhood apraxia of speech (CAS) can be viewed as both developmental and neurological has facilitated reimbursement for speech-language pathology services and may have broader implications. The ruling, made on a review, stated that developmental and neurological issues are not mutually exclusive, but both may exist in relation to a diagnosis.
Neurological Aspects
In December 2002, a father in Michigan filed a request on behalf of his young son that the Commissioner of Financial and Insurance Services review the denial of benefits for speech services by Blue Cross Blue Shield of Michigan (BCBSM).
The child had initially been diagnosed with suspected CAS and delayed expressive language skills. After a period of treatment, the speech-language pathologist subsequently confirmed the CAS diagnosis. The child demonstrated improvement through treatment and both the SLP and the child's physician stated that with further treatment the child would continue to improve.
While BCBSM admitted that speech treatment was a covered benefit under the insurance contract, they 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 was therefore not a covered service. BCBSM further claimed that the child was being treated for stuttering and for articulation errors, both of which they argued were developmental.
An Independent Review Organization (IRO) appointed by the insurance commissioner stated that speech disorders in children are often both developmental and organic and 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 review body also stated that the child's apraxia of speech and stuttering may have neuropathological correlates. Finally, the IRO noted that the child's speech treatment had benefited him and that the services were effective in the remediation of disorders that were both organic and developmental in nature. The commissioner then ruled that the child's condition was not strictly developmental in nature and therefore the speech therapy was a covered service.
Analysis and Implications
The ruling may be helpful in relation to insurance reimbursement for speech services for some children. While the decision was not rendered in a court of law and thus may not be controlling, it could be relevant and could potentially influence a judiciary decision. Additionally, the case could be referenced in other appeals of denials of speech treatment coverage. According to the Michigan ruling, BCBSM had 60 days from the date of the Insurance Commissions Order to seek judicial review. The date of the order was Jan. 31, 2003. As of June 1, 2003, per telephone inquiries to the Insurance Bureau, Department of Consumer & Industry Services in Michigan, no appeal had been filed and thus it is presumed that the ruling stands.
The term "developmental apraxia of speech" is misleading in that developmental implies to insurers that children will outgrow a speech impairment. However, according to David Hammer, coordinator of speech-language services at Children's Hospital of Pittsburgh, "the word 'developmental,' when used with apraxia, signifies a childhood disorder to differentiate it from adult acquired apraxia."
Visit (new window) to read the ruling from the Michigan Insurance Commission.
Sharon Gretz is the founder and a board member of the Childhood Apraxia of Speech Association of North America (CASANA). She is also the parent of a child diagnosed with apraxia of speech and will begin a doctoral program this fall at the University of Pittsburgh's department of communication disorders and sciences.
Kathy Bauer is an original officer and a board member of the Childhood Apraxia of Speech Association of North America (CASANA). She currently administrates the Apraxia-Kids Information Helpline, a program of The Hendrix Foundation and CASANA. Kathy is the parent of two children with apraxia of speech.
What You Can Do
Clinicians seeking reimbursement for childhood apraxia of speech should:
- Provide clear, initial information regarding apraxia of speech in children in written reports, progress notes, and informational letters to insurance companies. Be cognizant of the impact of your words-for example, use "childhood" instead of "developmental." Share information with families who are appealing denials.
- Insurance companies are interested in both treatment outcomes and efficacy. Clinicians will need to document outcomes of their interventions carefully. For a practical overview of treatment outcomes data from one facility, read "Functional Treatment Outcomes in Young Children with Motor Speech Disorders," by Thomas Campbell in Clinical Management of Motor Speech Disorders in Children, edited by Anthony Caruso and Edythe Strand. However, stopping at outcome data will not be enough. Campbell states that, "We need to move beyond outcomes data and start documenting treatment efficacy by carefully thinking through research design and experimental control questions in order to obtain interpretable clinical data to be collected and presented in a scientific way to the insurance industry." Clinicians will need to turn to researchers for these data.
- Stay current on the prevailing expert literature on the diagnosis and treatment of CAS and other severe speech production disorders. See produced for The Childhood Apraxia of Speech Association by the Hendrix Foundation, as one source of comprehensive, current, and easily accessible information. The two nonprofit groups have just recently released the print proceedings of the 2002 Childhood Apraxia of Speech Research Symposium, which is available for order through the apraxia-kids.org Web site. Although research related to apraxia is relatively sparse, the past 30 years have seen constant refinement and changes in the understanding of apraxia of speech in children and there appears to be increased interest in research and its clinical applications.
Available online at:
Summary:An independent review organization (IRO) concluded that apraxia and stuttering had both developmental and organic origins. Blues were ordered to pay per coverage policy. Please read the entire document to understand this order.
You may also view this order online at