Diagnosis Destinations Apraxia Appealing Insurance Denials Speech Therapy is not Medically Necessary

Reason for Denial: "Speech Therapy is Not Medically Necessary"

"Medically necessary" services are typically defined in the insurance contract as those:

"services rendered by a provider (physician, speech therapist) that are required to identify, treat or avoid illness or injury and are consistent with the diagnosis and treatment of the condition, appropriate regarding standards of good medical practice, not solely for the convenience of the member, and the most appropriate level of service which can be safely provided to the member."

According to each of these criteria, treatment of apraxia qualifies as medically necessary. ASHA (American Speech Language Hearing Association) describes verbal apraxia as "...a medical condition consistent with the definition of illness and disease, and that it is 'a disorder of body function,'"(see excerpt from Keystater, a publication of the Pennsylvania Speech Hearing Language Association, Sept. 1992.) Look at your insurance contract to see what definition is given for "medical necessity". Before you call your insurance company or HMO, be sure that you are informed about the applicability of the diagnosis of apraxia to their definition of medical necessity.

HMOs and insurance companies are not medical institutions. They are not qualified to assess medical necessity - the physician or therapist should do that. When HMOs and insurance companies tell you that something is not medically necessary, they are basically saying that, according to the information provided to them, the treatment is not medically necessary.

When you receive a "not medically necessary" denial, the first thing to do is to ask what is needed to prove medical necessity. Try to pinpoint what data they are lacking. Often a clerk at the insurance company has misunderstood the speech therapist's diagnosis, a document was not received or has been misplaced, etc. Act as the liaison between the insurance company and your child's speech therapist's office and provide them with copies of the paperwork, physicians' statements, etc. Your health care providers need to be assertive (and may need prompting from you) and must specify that the therapy is medically necessary (and must provide specific reasons why). Also, it is perhaps advisable to refer to therapy as "treatment" (ex: Recommendation for child's treatment for apraxia of speech is three times per week). Sometimes this word helps to conjure up the appropriate medical image.

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