SilentFax@ IMEDECS Mar 26.

15 14:53 From: Shannon Mayer To: Nina Doss Page 2

I. El>E C S
ircdf.>p1:>t?dEmt !vWdical Expert Consulting Sr:>fYic~.udnc.
Berke-Weiss Law PLLC | www.berkeweisslaw.com

March 26, 20 I 5

Case#:
Health Plu n: (h:fi)rd Health Plan
Denied Heahh s~rvice or Treatment : Sp<~ech generating device (Prc~Service}
Denial Re.as1.it1: \fodical Ncce-ssi.ty

Dear :

Atta...:hed picas"-' find thu ci..:pcrt reviewer repo rt tbr your n::quesll:.-d exkmal appealre,,i1::v. pursuiult to the
New York Pul:>lic. Health !..aw. Article49:

Jl'v1EDECS atksts that no prohibitd n1aterial affiliation existed ,vith respect lo the dinical peer
re\' iewer( '>}

The re~'iewer has dedded to oH~nurn the health plan's dedsion~

Summan of Exnert's Qualifications

Reviewer
ls a d~1etou,f m,teopalhy ( DO)board <:t:rtitit:d in phy:;ical medic.ine and rehabilitation and sp1:,rts medicine
at
with an active practice a university medical c1.mtcr. Felk,v.-ship completed in non-operative spine care.
Serve~ as dinica l instructor of rehabilililti<m med k ine at a sch<X}l 1>fmcdicine. U.,-cture~ bv invit.3tioo and
is active in profossional societies,Publi:,ht?d in f)OOf reviewed literature. . .. .

If you have any queslxons, please cont.let your heullh plan. Oxfrmi lfoahc1 P lan. ;\ copy of this
informatic,n has abl> been ~mt to them ,

Sincerely,
;:.'.{?}'',.___,_......
Jennifer Young, RN
Case Rev iew Manager
SM/mvh
Cc : K1mbe.rly Day/Oxford Health Piao
Nina. Doss!N'YSDFI;,

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SilentFax@ IMEDECS Mar 26. 15 14:53 From: Shannon Mayer To: Nina Doss Page 3

Case Number: Berke-Weiss Law PLLC | www.berkeweisslaw.com

Patient:
Reviewer Number:
Page 1 of 1

Summary

The patient is a ~ith a past neurological history significant for cerebral palsy
(CP) and dysarthria. CP is characterized by spastic quadriplegia and significant oral motor
deficits such that is not able to effectively verbally communicate. uses gestures, grunts,
and approximations to express needs.

is of normal intelligence, has sound receptive language capacity, and is without a

hearing or visual impainnent. At issue is the medical necessity of a speech generating device
(SGD) which uses high-tech eye gaze selection (i.e., DynaVox Communication System's Tobii
1-12), as traditional speech therapy has failed and lower tech devices are not appropriate for the
patient's condition.

Question(s):

I) Has the health plan, in its determination of medical necessity, acted reasonably, with sound
medical judgment, and in the best interest ofthe patient?

No. The health plan has not acted reasonably, with sound medical judgment, or in the best
interest of the patient in its detennination of medical necessity.

2) Is the requested health service/treatment ofSGD medically necessary for this patient?

Yes. The requested SOD using high-tech eye gaze selection (i.e., DynaVox Communication
System's Tobii I~ 12) is medically necessary for the patient. I disagree with the denial rationale
which states, in part, that the "documentation does not support the requested SGD is the
equipment lhat meets the minimum specifications for the member's needs."

CP does not allow to control hand-held communication devices. has not

been able to improve expressive language deficits with traditional speech therapy. has
proven to be able to operate a high-tech eye gaze selection system mounted to wheelchair.
Lower tech options such as manual direct select systems are not appropriate given the patient' s
poor volitional motor control, fine motor skills, and coordination.

3) Do you uphold or overrurn, in whole or in part, the health plan's determination of medical
necessity?

The health plan's determination of medical necessity is overturned. in whole. The requested
SGD meets the minimum specifications for the patient's needs as stated above.

Refere11ce(s):

1. Yorkston KM, Treatment efficacy: Dysarthria. J Speech Hear Res. l996;39(5):S46.

2. Nordberg A., et al. Speech problems affect more than one in two children with cerebral
palsy. Acta Pediatr. 2013 Feb;102(2): 161-6.