Ins Co USA

100 Middle Street

Anytown

July 24, 2002

RE: Insured: John Doe

ID #: PBJ000000

Dear Dr. Smith,

I am writing this letter in behalf of Mr. John Doe who is appealing your decision to deny coverage for treatment of his stuttering disorder. It seems as if we must address two issues: one, that stuttering treatment is not covered since your company considers it not to be due to an “illness or injury” and two, that this service was provided by an out of network provider. We are requesting reconsideration based on the following information.

It appears that what is necessary here is to redefine and reclassify the disorder of stuttering as a medical condition, a disorder for which speech therapy is essential and one that is not a “functional nervous disorder”. The coding in ICD-9-CM for classifying the disorder of stuttering is seriously outdated and does not represent current research findings in this area. In fact, with the publication of the ICD-10-CM, this will be changed. It is our hope that your staff can look beyond the erronious current coding and agree to consider coverage for Mr. Doe’s treatment.

This letter is a summary of such research which substantiates stuttering to be a medial condition for which speech therapy is essential and such treatment, therefore, should be covered by your insurance company. I am enclosing statements from the President of the Stuttering Foundation of America and from the American Speech, Hearing and Language Association which support this issue.

As stated in the book Stuttering Then and Now by Shames and Rubin (1986): ....”the bulk of the work has yielded evidence that clearly indicates that stuttering involves some kind of anomalous function in the central nervous system. Research of a related nature, designed to explore central nervous system functions not specifically pertinent to the matter of laterality has yielded additional evidence of central nervous system anomalies in stuttering (for example: Sayles, 1971; Stromsta, 1972; Cooper & Allen, 1977; Hall & Jerger, 1978; Toscher & Rupp, 1978; Moore & Haynes, 1980; Decker et al.,1982)....much investigation has been addressed to laryngeal function and voicing in stuttering (for example, Adams & Reis, 1971, 1974; Freeman & Ushijima, 1978; Cross et al.m,1979; Reich et al.,1981; Watson & Alfonso, 1982; Cross & Luper, 1983).

Again the bulk of this research has yielded evidence of anomalous laryngeal and voice function in stuttering. ...In sum, recent research in the several areas of investigation reviewed above concur in providing a substantial body of evidence that stuttering represents, in a variety of ways, the product of aberrations in physiological function.”

More recently, as reported in the November 5,1996 edition of The Medical Post, a research study conducted by Dr. Luc DeNil of the Toronto Hospital and associate professor of Speech Language Pathology at the University of Toronto, is concluding that stuttering is a biological/medical condition. They found that persons who stutter tend to rely on the right hemisphere of the brain to speak as opposed to the left side, which is used by most normally fluent speakers.

Through the use of positron emission tomography (PET) technology has allowed them to be more specific in locating the regions of the brain involved. Their study also showed, for the first time, that patients who become more fluent immediately following an intensive treatment program (such as this treatment) exhibit increased activation in the left motor regions of the brain, an area of expected activation in non-stuttering speakers. This research clearly identifies stuttering as a neurophysiologically based biological/medical condition.

Additionally, Dr. Smith , Speech - Language Pathology services are health related service. In this particular case, the speech pathology services are provided for treatment of a medical condition, that is stuttering. Speech -language pathology services are recognized as healthcare services by the U.S. Department of Health and Human Services as well as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).

The Health Insurance Association of America (HIAA) has issued a report recognizing the importance of Speech-Language Pathology and Audiology services. In addition, you should know that speech-language pathologists are licensed in 40 states in order to protect the public health.

The fact that stuttering is a physiologically based disorder has been substantiated. To further substantiate it to be a medical condition (illness, sickness) for which treatment/therapy is medically necessary. Presented here are excerpts from Pediatrics, 71(1), pp. 135-136, January 1983, a journal published by the American Academy of Pediatrics.

“...1. illness - a condition marked by a pronounced deviation from the

normal, healthy state.

2. healthy - free from disease or dysfunction.

3. health - normal condition of body, mind, with all parts functioning

normally. This being the case, stuttering would be a deviation from the

normal, healthy state. The patient is not free from disease or dysfunction,

and he/she does not enjoy al his/her parts functioning normally.

A physician’s referral of a patient to a speech pathologist means he/she considers stuttering to be an illness, treatable, medical condition, and

one that would require treatment. In his/her opinion, therapy is

necessary to bring the patient to a normal, healthy state.”

The information provided here clearly designates this speech disorder to be a medical condition which is treatable by speech therapy, a healthcare service. Treatment is considered to be medically necessary by the referring physician. This, therefore, would be an appropriate claim for coverage by your company.

Next, I’d like to address the necessity for Mr. Doe to go out of network for this treatment. I will present empirical as well as anecdotal evidence supporting the effectiveness of [intensive and] specialized treatment for stuttering, supporting his choice to seek out of network treatment.

Highly specialized, [intensive] treatment for the disorder of stuttering has existed for at least the past three decades and has undergone extensive refinement and scrutiny within our profession, as do the more traditional non- intensive approaches. The existence of intensive treatment programs is growing in this and other countries which indicates the fact of its strengths and benefits.

Of the approximately 60,000 certified speech-language pathologists in the United States, only 299 have been designated as Board Recognized Specialists in the Treatment of Fluency Disorders. I have over 22 years specializing in the treatment of stuttering and have worked with approximately 2000 people who stutter.

I will provide some results from studies conduced that directly speak to the effectiveness of intensive stuttering treatment programs. This first study is based on an intensive program conducted at The Institute for Stuttering Treatment and Research (ISTAR) in Edmonton, Alberta, Canada. The program conducted here at the American Institute for Stuttering is essentially the same as the program at ISTAR.

“Long Term Results of an Intensive Treatment Program for Adults and Adolescents Who Stutter” (Journal of Speech & Hearing Research, Volume 37, 1050-1059, October, 1994, E. Boberg & D. Kully). The synopsis is as follows:

“ In order to determine the long-term effects of an intensive treatment program, 17 adult and 25 adolescent stutterers were tested 2 or 3 times during a 12-24 month post-intensive treatment phase. The results of this study are intended to augment and supplement the growing body of evidence about the effects of intensive treatment programs on adult and adolescent stutterers. Follow-up measures included surprise phone calls to clients at home/work and a self administered Speech Performance Questionnaire. Careful training of speech raters was undertaken to insure high reliability of speech measures. Results from the phone call samples indicated that about 69% of the subjects maintained a satisfactory level of post-treatment fluency, with an additional 7% maintaining a level that was judged to be marginally satisfactory. On the self-administered Questionnaire, 80% of the subjects rated their speech fluency as good or fair 12 to 24 months after treatment.”

Another study was conducted at the same facility: “Results of an Intensive Stuttering Therapy Program” (Logopedie an Foniatrie, Volume 17, Numbers 3 & 4, September-December 1993, M. Langevin & E. Boberg)

“This paper reports the results of a three week intensive program for 10 adult and adolescent stutterers. Measurements were made immediately before and after treatment and again during the follow up period, 12-14 months post-treatment. The measures included percentage of stuttering, syllables spoken per minute and three self report scales designed to measure changes in attitudes, perceptions and self confidence. In the follow-up period, subjects completed a fourth scale in which they indicated their level of satisfaction with with their speech performance. The results indicated that substantial positive changes occurred and were maintained in both speech performance and non-speech variables.”

A survey was independently conducted in 1989 by the ICR Survey Research Group on past participants in intensive treatment at the Communications Reconstruction Center in New York which was the predecessor to the American Institute for Stuttering. These participants had undergone treatment from 1985 to 1988. 91% of the 200 past participants surveyed reported that the program was highly worthwhile for them. About 81% reported a substantial increase in self-confidence.

Just as the amount of observable/external dysfluency does not reflect the full extent of the impact that stuttering has on one’s life, isolated measures of fluency levels do not reflect “success”. Success must be considered from other perspectives: confidence, a sense of freedom, empowerment in one’s life, and satisfaction reflect deeper, more internal changes: that the individual no longer feels the burden of handicap.

I have offered a sample of the empirical evidence that supports the overall effectiveness of this treatment approach. I would like to add some anecdotal evidence as well. This comes in the form of client report and was received by me without solicitation. These were simply expressions of gratitude from my clients and reflect the deeper quality of life changes that occur as a result of treatment.

“You and the program have had more of a positive influence on my life than anyone I’ve ever met. You’ve renewed in me the belief that I can start over, that 19 years of stuttering has not wholly crushed my spirit. I really think that I now have the will to change and you’ve certainly given me the means, so I think the coming months will lead certainly to greater fluency and maybe even some day, total fluency. Stutterers are fortunate to have a person such as yourself working in this field.” Student...Staten Island, New York

“Cristin’s progress to date has been outstanding. She demonstrates a true sense of ownership and control of her speaking which reinforces her confidence level. She has replaced anxiety about speaking with a feeling of enjoyment. Dread has been replaced by excitement. Without a doubt, it is the very special, supportive environment that Catherine creates which I feel results in the many successes that she must enjoy.” Director of Training & Development, The New York Times, father of Cristin......Beacon, New York [at least one year post treatment]

“Catherine Montgomery has been my colleague, mentor, clinician and good friend for the last fifteen years. She is an outstanding clinician with innovative ideas and a great desire to help those who stutter. The love of her work is reflected in the dramatic results she has with her clients. She has helped over a thousand stutterers, including myself, lead fuller and more productive lives. In fact, if it were not for her, I would be a security guard on the 3rd shift rather than a university professor with over 30 peer-reviewed publications in the filed of stuttering. Her devotion to her clients changes lives!” Professor, East Carolina University [15 years post treatment]

To summarize, there is a preponderance of evidence that supports the effectiveness of specialized, state-of-the-art intensive stuttering treatment. Should you have any further questions, please contact me.

Very truly yours,

Catherine S. Montgomery,M.S.,CCC-SLP

Director

ais@stutteringtreatment.org