September 5, 2002

 

 

Dr. Smartguy, MD, MBA

Medical Director

Meanguy insurance co.

 

 

Dear Dr. Smartguy,

 

This letter is the notification to appeal the decision of Aetna US Healthcare to deny coverage for speech therapy for our son, ***** ******. 

 

Our copy of the health plan, as well as the service bulletin sent to us by Aetna US Healthcare, state that we are entitled to speech therapy for “restoration of speech lost due to disease or accident”, and in the case of stuttering, when it is related to “a specific disease, injury, or congenital defect”.  On the basis of these documents and all current research into the causes of persistent stuttering we believe ********* is indeed entitled to speech therapy coverage.  We believe Aetna U.S. Healthcare is mistaken in excluding his coverage and this exclusion is based on outdated information.

 

Although stuttering was once considered a “psychogenic” disorder, recent advances in brain imaging have clearly shown distinct abnormalities in the brains of stutters with respect to speech production.  Stuttering is now considered to be a neurologically based disorder by neurologists and speech pathologists who specialize in fluency disorders.  XXXXX lost his ability to produce fluent speech because of aberrant neural activity in the areas of his brain responsible for speech production.  Moreover, genetic research suggests he inherited this disorder.  XXXXX is entitled to speech therapy services for the restoration of fluent speech now lost due to a congenital neurologic abnormality.

 

It has long been suspected that stuttering was caused by a distinct cerebral abnormality for a number of reasons including: the strong male prevalence, the fact that most dysfluencies occur at specific times during speech production (the beginning of sentences), the fluency-evoking potency of singing (which activates a different area of the brain not involved with conversational speech production), the much higher concordance in monozygotic twins than dizygotic twins, as well as the much higher incidence of persistent stuttering in children with a family history of persistent stuttering. 

 

In recent years exciting advances in brain imaging as well as renewed interest in stuttering by the medical community have made it possible to perform a variety of investigations and clearly demonstrate an organic cause.  The imaging modality that has proven to be the most helpful has been positron emission tomography (PET).  Volumetric MRI, magneto-encephalography (MEG), and trancranial magnetic stimulation (TMS) have also been utilized.  Brain imaging clearly demonstrates that the brain of the stutterer is abnormal with respect to the areas responsible for the production of speech—even when they are not stuttering.2  The most recent investigations conclude that stuttering is a disorder affecting multiple neural systems used for speaking.  These findings implicate the speech-motor regions of the non-dominant cerebral hemisphere (usually the right) in those who stutter.3  This area of the brain is not normally used for the production of speech.  This new evidence is so intriguing that it has been reported on by the general press, evidenced by a recent article in U.S. News and World Report.4

 

XXXXX has three first-degree relatives who have persistent stuttering into adulthood. His stuttering does not represent normal developmental disfluency.  The chances are extremely low that his stuttering will regress without therapy.  Early intervention is the key to restoring a basic communication tool, his ability to speak, without the unavoidable social stigma that has been placed on stuttering in our society and the secondary issues that are a result.

 

We are fortunate to have access to the new Stuttering Program of the Center for Childhood Communication at the Children’s Hospital of Philadelphia.  This program incorporates the latest technology and clinical advances in the field of childhood stuttering.  The program is not lengthy or expensive. XXXXX will need the intensive, once a week, therapy for another 3 to 6 months and then “maintenance” visits as determined by his progress and evaluation by his speech pathologist. XXXXX began their treatment program in May and had already made significant progress.

 

While Aetna US Healthcare’s medical committee reviews the current research into the causes of stuttering and its policy therein, we respectfully request that an exception be made in XXXXX’s case and insurance coverage be provided for the program he has already begun.  We believe this is a reasonable request for coverage of a program with proven efficacy in a reasonable period of time.  If Aetna US Healthcare is not amenable to providing this coverage, even with the additional information that we have provided, we respectfully request going forward with our complaint to an independent appeal panel as within our rights per Act 68.

 

Thank you for your time and attention.

 

Sincerely,

 

********

*********   

 

 

 References:

 

1. Ingham, R. (2001) Brain imaging studies of developmental stuttering. Journal of Communication Disorders. 34:493-516

 

2. Foundas AL; Bollich AM; Corey DM; Hurley M; Heilman KM. (2001) Anomolous anatomy of speech-language areas in adults with persistent developmental stuttering.  Neurology. 57:207-15

 

3. Fox PT; Ingham RJ. et al. (2000) Brain correlates of stuttering and syllable production. A  PET performance-correlation and analysis.  Brain. 123:1985-2004

 

4. Gordon N. (2002) Stuttering:  incidence and causes.  Developmental Medicine and Child Neurology. 44:278-81

 

5. Rosenfield DB. (2001) Do stutterers have different brains?  Neurology. 57:171-2

 

6. Sendak R.; Fiez JA. (2000) Stuttering: a view from neuroimaging.  Lancet.  356:445-6

 

 



2 Ingham R. (2001)  Brain imaging studies of developmental stuttering.  Journal of Communication Disorders. 34:493-516

3 Gordon N. (2002)  Stuttering: incidence and causes.  Developmental Medicine and Child Neurology. 44:278-81

4 Sobol R. (2001)  Anatomy of a Stutter.  U.S. News and World and World Report.  April 2, 2001