Issued and entered March 21, 2003 by Frances K. Wallace, Chief Deputy Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On October 7, 2002, XXXXXXXXXX, on behalf of her son XXXXXXXXXXXX (“Petitioner”), filed a request for external review with the Commissioner of the Office of Financial and Insurance Services under the Patient’s Right to Independent Review Act, (“PRIRA”) MCL 550.1901 et seq. After a review of the material submitted, the Commissioner accepted the request. Because a medical question is central to the proper resolution of the appeal, it was assigned to an independent review organization (“IRO”), as provided in section 11(6) of the PRIRA, MCL 550.1911(6). The IRO submitted its external medical review on November 1, 2002.

II
FACTUAL BACKGROUND

Petitioner is a Blue Cross Blue Shield of Michigan (“BCBSM”) member. He seeks coverage for speech therapy to treat expressive language function problems associated with apraxia and dysarthia. BCBSM denied Petitioner coverage for the speech therapy he obtained from XXXXXXX to XXXXXXXXXXXXXX, on the grounds that it was for the treatment of a developmental delay. Petitioner claims that apraxia and dysarthia are neurological disorders and not developmental disorders. He has exhausted BCBSM’s internal grievance procedures, and BCBSM issued a final adverse determination in his case on August 9, 2002.

III
ISSUE

Is BCBSM required to pay for Petitioner’s speech therapy?

IV
ANALYSIS

PETITIONER’S ARGUMENT

Petitioner argues BCBSM should cover his speech therapy, because it is a medical necessity due to apraxia and dysarthia. He contends that apraxia and dysarthia are neurological disorders, and these conditions meet the criteria for coverage of speech therapy contained in the Comprehensive Health Care Copayment Certificate – Series CMM 250. Petitioner also points out that he has made dramatic improvements in motor-speech proficiency, expressive language function, and overall behavior, since beginning speech therapy in XXXXXXXXXXXX. He asserts that he would not have made these gains without speech therapy, and if his treatment stops, he will not be able to progress any further. Petitioner therefore argues that the Commissioner should reverse BCBSM’s final adverse determination in this matter.

BCBSM’S ARGUMENT

In its August 9, 2002, final adverse determination letter to Petitioner, BCBSM stated:

As indicated [in] the Comprehensive Health Care Copayment Certificate – Series CMM 250, speech therapy services are payable. However, payment is not included for long standing chronic conditions, developmental conditions or learning disabilities or for congenital or inherited speech abnormalities.

In this instance, our medical consultants reviewed the documentation and the information provided…and confirmed that the apraxia is a developmental condition. Because [Petitioner’s] coverage does not include benefits for speech therapy rendered for developmental conditions, payment cannot be approved.

IRO’S RECOMMENDATION

The IRO expert who reviewed this case is a board certified pediatric speech therapist. The IRO expert recommended that the Commissioner reverse BCBSM’s final adverse determination in this case, based on the following conclusions:

• Petitioner’s speech therapy records support a diagnosis of apraxia with a secondary diagnosis of dysarthia.
• Apraxia is a motor speech disorder that is neurological and not developmental.
• Dysarthia is an oral motor disorder that indicates a specific illness and is not related to developmental delay.
• Both diagnoses of apraxia and dysarthia are organic in nature.
• Petitioner’s language skills and speech errors are not indicative of developmental delay.
• Petitioner meets BCBSM’s criteria for coverage of speech therapy services.

COMMISSIONER’S REVIEW

The Commissioner carefully reviewed the arguments and documents the parties submitted, as well as the findings of the IRO expert. The focus of this analysis is whether BCBSM properly denied Petitioner coverage for speech therapy, according to the Comprehensive Health Care Copayment Certificate – Series CMM 250 that controls his coverage. The Certificate, in pertinent part, states:

Physical, Speech and Occupational Therapy Services
We pay for physical therapy, speech and language pathology services, occupational therapy to treat disease or injury.
Speech and language pathology services must be:

• prescribed by a physician licensed to proscribe them; and
• given for a condition that can be significantly improved in a reasonable and generally predictable period of time (usually about six months), and
• given by a speech-language pathologist certified by the American Speech-Language-Hearing Association or by one fulfilling the clinical fellowship year under the supervision of a certified speech-language pathologist.
  Services do not include:
• long-standing chronic conditions;
• developmental conditions or learning disabilities, or
• congenital or inherited speech abnormalities.

This language clearly outlines BCBSM’s criteria for speech therapy benefits and lists certain conditions for which BCBSM will not cover speech therapy. The Certificate specifically excludes speech therapy for developmental problems from BCBSM coverage. In Petitioner’s case, BCBSM denied him benefits for speech therapy based on its determination that he received those services to compensate for developmental delay. However, the IRO expert who reviewed this case found that Petitioner’s conditions requiring speech therapy—apraxia and dysarthia—are not developmental. The IRO medical expert also found that Petitioner meets BCBSM’s criteria for coverage of speech therapy. The Commissioner agrees with these findings, and therefore concludes that Petitioner’s speech therapy from XXXXXXXXX to XXXXX XXXXXXXX, is a covered benefit.

V
ORDER

BCBSM’s August 9, 2002, final adverse determination in Petitioner case is reversed. BCBSM must provide Petitioner with coverage for the speech therapy he underwent from XXXXXXXXX to XXXXXXXX, XXXX. BCBSM must make payment within sixty days of the issue of this order and shall provide the Commissioner with proof of payment no later than seven days after it makes that payment.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this order may seek judicial review no later than sixty days from the date of this order in the circuit court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.