Re: Medical Necessity - to (sample letter of med necessity pasted)

[Guest guest]

Hi, and others. Here's a letter I wrote and used successfuly to appeal a

denial of insurance coverage on the basis that apraxia is developmental. This

letter shows that apraxia is neurological and therefore medical, not

developmental. Feel free to use, share, etc. HOpe it helps someone out there!

SAMPLE LETTER:

[DATE]

VIA CERTIFIED MAIL/RETURN RECEIPT REQUESTED

[iNSURANCE CO INFO]

To Whom It May Concern:

My son, __________, has been diagnosed with apraxia by his pediatrician, his

pediatric neurologist, and his speech and language pathologist. (See enclosed

information). To remediate this condition, has been receiving

speech and language therapy as well as occupational therapy (the apraxia affects

his oral motor musculature as well as his fine and gross motor functions). His

progress has been excellent, and all concerned believe continued therapy is

crucial to overcome this condition.

[HERE I DISCUSSED ENCLOSURES: LETTERS FROM PEDIATRICIAN, SLP, OT]

Since apraxia is a relatively uncommon condition, let me explain briefly what

it is. Apraxia “’is a neurological disorder that affects the planning and

production of speech.†(, Jakielski, & Marquardt, 1998)’…[it] is a

loss

in ability to voluntarily position the articulators (e.g., lips, jaw, tongue)

on a consistent basis when speaking. This disorder interferes with the child’

s sequencing of sounds into words. In other words, the child has the ability

to produce the sounds, but when he/she tries to purposefully plan speech, the

articulators do not always function together properly.†S. Whitebreak, C.

Dvorak, and K. Jakielsi, “Treatment Effect on Speech Intelligibility in

Developmental Apraxia of Speech,†Presentation at the American

Speech-Language-Hearing

Association, 1999. “’…This disability has a neurological basis of unknown

origin. It may reflect neuro-anatomical/physiological differences that are

inherited (see Hurst, Baraitser, auger, Gramah, and Norell, 1990; Shriberg,

1993)

or damage that occurs pre- or postnatally during the period of speech

development (Crary, 1984; Marquardt and Sussman, 1991)…†It is similar to

the

condition stroke victims suffer from when they lose the ability to speak after a

stroke. In fact, many children initially have speech ability but then lose it

(as is the case with , who had a larger vocabulary at 18 months of age

than when diagnosed at 25 months of age).

As to medical necessity of treatment of apraxia, the American Speech Hearing

Association (ASHA) defines verbal apraxia as “a medical condition consistent

with the definition of illness and disease…’a disorder of body

function.’â€

(Keystater, the official publication of the Pennsylvania Speech Hearing

Language Ass’n, Sept.. 1992; Source: ASHA, Rockville, MD).

Apraxia is not a developmental disorder or delay. If left untreated, my son

will not develop meaningful speech or coordinated fine and gross motor

abilities. Lack of meaningful speech and fine and gross motor abilities would

result

directly in a deterioration of my son’s health and safety, in that he will

not be able to communicate medical needs and will be unable to function and do

daily life skills. With treatment, however, the prognosis is good. In fact,

_____'s progress has been excellent.

Speech and occupational therapy are the recommended treatments for apraxia

(see enclosed letters). They are the least expensive, least invasive, and most

successful forms of treatment, are accepted by the medical community, and are

not implemented for the convenience of the child or therapist. See also a

Square, “Introduction,†Clinics in Communication Disorders, 4(2) (“apraxia

is a motor speech disorder in the ability to regulate and control oral movement

sequences. Apraxia is a separate speech disorder that requires a motor

treatment, apraxia is remediable if the clinician knows that this must be the

focus

of treatmentâ€); Penelope Hall, Jordan and Robin, “Theory and

Clinical Practices†(“Intensive services are needed for children with

apraxiaâ€

); Edythe Strand, “Childhood Motor Speech Disorder Treatment,†(“The

earlier

and more intensive the intervention, the more successful the therapy…Children

with apraxia really need the intensive individual therapyâ€).

In fact, the research indicates and experience dictates that apraxic children

need intensive consistent therapy. The leading researchers in the field have

indicated that this is the best therapeutic route to take. Such researchers

include Edythe Strand, PhD., Mayo Clinic; a Square, Ph.D., University of

Toronto; and Robin, Ph.D., University of Iowa. The research indicates

that the key to success is intensive therapy continually throughout the year.

In short, since apraxia is a medical condition and not a developmental delay

or disorder, and since speech and occupational therapy are medically

necessary, I submit that the enclosed expenses should be a covered benefit under

the

plan. Thank you for your consideration.

Sincerely,

Sandy, Illinois (alpy2@...)

Volunteer Co-Webmaster, www.ourchildrenleftbehind.com (IDEA reauthorization)