(reprinted with permission from the Office of Financial and Insurance Services, Department of Consumer & Industry Services, State of Michigan)
January 31, 2003
File No. 51428-001
XXXXXXXXXXXXX Blue Cross Blue Shield of Michigan
Issued and entered January 31, 2003 by Frank M. Fitzgerald, Commissioner
I: PROCEDURAL BACKGROUND
On December 18, 2003, XXXXXXXX filed, on behalf of his minor son, XXXXXX (Petitioner), a request for external review with the Commissioner of Financial and Insurance Services (Commissioner) 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. The issue involved is medical in nature. The Commissioner therefore assigned it to an independent review organization (IRO) on December 27, 2002. On January 13, 2003, the IRO provided its recommendation to the Commissioner.
II: FACTUAL BACKGROUND
Petitioner, who is XXXXXXXXX, received speech therapy from XXXXXXXXX through XXXXXXX. BCBSM denied payment for this care because it claimed Petitioner’s speech problem was developmental. The BCBSM Certificate excludes speech therapy for development speech problems.
Petitioner’s father claims Petitioner’s speech therapy is a covered benefit and therefore BCBSM is required to pay for it.
Whether Petitioner’s speech therapy is a covered benefit under his BCBSM Certificate of Coverage?
XXXXXXXXXXXXX evaluated Petitioner in XXXXXXXX , and diagnosed him with potential verbal apraxia and delayed expressive language skills. Petitioner began speech therapy in XXXXXXXXXXX. At this time, Petitioner was diagnosed with verbal apraxia. By XXXXXXX, Petitioner improved significantly. Both the speech therapist and Petitioner’s doctor indicated that further therapy was required in order for his improvement to continue.
BCBSM eventually paid for all of Petitioner’s speech therapy through XXXX. However, BCBSM denied coverage of Petitioner’s speech therapy provided in XXXX. BCBSM claimed that Petitioner’s speech therapy was not a covered benefit and that it paid for Petitioner’s XXXX speech therapy because it was provided incorrect information.
Petitioner’s father claims that verbal apraxia is a neurological based speech disorder caused by subtle brain malfunction in the area of the brain that tells the muscles how to move and what to do to make a sound or series of sounds.
Petitioner’s father claims that treatment of verbal apraxia is a covered benefit under the BCBSM Certificate. He contends that BCBSM is therefore required to pay for Petitioner’s speech therapy which was provided in XXXX.
Petitioner is enrolled as a dependent under his father’s contract through XXXXXXXXXX, an area rated group. The Community Blue Group Benefit Certificate governs the coverage. Speech therapy is a covered benefit under this Certificate. However, this Certificate also indicates that speech therapy services do not include “developmental conditions or learning disabilities”.
BCBSM claims that Petitioner’s condition is developmental and therefore his speech therapy is not a covered benefit. The therapy notes for XXXX indicate Petitioner received speech therapy for stuttering and for articulation defect, which BCBSM claims are developmental conditions. BCBSM also claims that by XXXXXXXXXXX, Petitioner’s family was aware of the fact developmental conditions were not a covered benefit under the certificate. Therefore, BCBSM contends that it is not required to pay for Petitioner’s speech therapy which was provided in XXXX.
Independent Review Organization (IRO) Recommendation
The IRO indicated that children’s speech disorders are often both developmental and organic and that these two descriptors are not mutually exclusive. The IRO also indicated that although Petitioner’s speech- language problems appeared to be long-standing, developmental and possibly congenital in origin, they are neurologically based and therefore organic as well. The IRO further indicated that Petitioner’s apraxia and stuttering may have neuropathological correlates. Finally, the IRO indicated that Petitioner’s speech therapy helped him progress toward the goal of this intervention. Based on the information and documentation provided him, the IRO concluded that the speech and language therapy services, which Petitioner received through XXXXXXXXXXXX, was effective in targeting conditions that were both organic and developmental.
The Certificate of Coverage controls the analysis of whether a particular service is a covered benefit. Speech therapy is a covered benefit under Petitioner’s BCBSM Certificate. However, the Certificate is also clear that speech therapy for treatment of developmental delays is not a covered benefit.
BCBSM denied payment for the speech therapy which was provided Petitioner in XXXX on the basis that it was treatment of a developmental condition. However, the IRO concluded that the Petitioner’s apraxia and stuttering have both developmental and organic origins. That is, neuropathic abnormalities can cause both these conditions. The Commissioner’s agrees with this conclusion and therefore finds that Petitioner’s conditions are not strictly developmental. Petitioner’s speech therapy treated at least in part, an organic condition. Therefore, Petitioner’s speech therapy, which was provided in XXXX, is a covered benefit under the Certificate.
Therefore, the Commissioner ORDERS that the final adverse determination of BCBSM dated October 17, 2002, is reversed. BCBSM is required to pay for the speech therapy which was provided to Petitioner over the period of XXXXXXXXXXX until XXXXXXXXXXX . BCBSM is required to make this payment within sixty days and shall provide the Commissioner proof of payment no later than seven days after payment is made.
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.