Medical Policy: 08.03.05
Original Effective Date: June 2004
Reviewed: March 2016
Revised: March 2016
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Speech therapy involves the evaluation, diagnosis and treatment of communication impairments and swallowing disorders. Speech-language pathologists (sometimes informally referred to as speech therapists) evaluate and treat disorders and impairments resulting from illness, trauma, disease, or congenital anomaly including: speech articulation, apraxia, and phonological disorders; voice disorders; oral pharyngeal dysfunction and related disorders; and cognitive, language, and communication disorders.
The speech therapy services provided are intended to cover only episodes of therapy for situations where there must be a reasonable expectation that a patient’s condition will improve significantly in a reasonable and generally predictable period of time.
The use of devices such as iPads, computers, etc. not manufactured specifically for the use of speech and language therapy would not be considered a payable benefit. This is related to the device. Speech therapy would follow the criteria below, whether performed on an iPad, computer, etc. or not.
Prior approval is required.
Submit a prior approval now.
Speech therapy services may be considered medically necessary when they are related to a specific injury, illness, impairment, or disease and involve the mechanics of phonation or deglutition and meet all of the following criteria:
- Are performed to meet the functional needs of a patient who has a physical disability or a communication disability or swallowing disorder due to illness, disease, injury, congenital anomaly, or prior therapeutic intervention.
- Are performed to meet a specific diagnosis-related goal for a patient who has the potential to achieve measurable improvement in a generally predictable period of time.
- Require the judgment, knowledge, and skills of a qualified provider of speech therapy services, i.e. speech pathologist, speech-language pathologist, or speech clinician because of the complexity and sophistication of the therapy and the physical condition of the patient.
Indications for which speech therapy services may be considered medically necessary include, but may not be limited to:
- Brain injury or insult due to cerebrovascular accident or trauma
- Structural anomalies related to cleft palate and cleft lip
- Neuromuscular disorders such as cerebral palsy
- Pervasive developmental disorders including but not limited to:
- Autism spectrum disorders
- Asperger syndrome
- Childhood disintegrative disorder (also known as Heller syndrome)
- Rett syndrome
- Speech therapy for developmental disorders must require the need of a therapist. For example: Word drills, work on communication boards, and work on behavioral issues surrounding speech would not be a specialized need for therapy. Through therapy there must be achievement of goals that are unachievable through the use of home drills.
- Paradoxical vocal cord disorder
- Vocal cord nodules
- Sensorineural hearing loss
- Dysfunction occurring as a result of a therapeutic process such as vocal cord surgery, laryngectomy, radiation therapy, or ototoxic medication
- Developmental Apraxia of Speech (oral motor apraxia)
There should be the expectation by the provider that there will be significant improvement with 3 months of speech therapy. This shall be reflected in goals and treatment plan.
Note: Prior Approval is not needed for the initial speech therapist’s evaluation.
Documentation Required for Prior Approval
Minimum acceptable documentation, in the form of a speech language evaluation with short and long-term goals, will include the following:
- Results from standardized testing that measures overall receptive and expressive language, using standard scores or age equivalencies for pediatric assessments and determinations of deficits in adult assessments as applicable.
- Results from standardized testing that measures articulation, using standard scores or age equivalencies and including a description of any noticeable error patterns and a description of stimulability for correct production of error sounds.
- Language sample including a Mean Length of Utterance (MLU) and a description of the types of words used by the patient in conversational language. For patients with Developmental Apraxia of Speech (oral motor apraxia), also include results from diadochokinetic testing (maximum repetition test) and oral motor examination (including ROM, strength, impaired coordination, groping and oral management of food).
Children older than two years must show a minimum of 12 months difference between their chronological age and their age equivalency on standardized tests in any one language area, or the standard score must fall at least one standard deviation below the normal range as designated by the standardized instrument utilized.
Language tests that measure only a specific area, such as receptive vocabulary may be included but only as an additional measure to quantify areas of strength and weakness.
In order to reflect that continued services are medically necessary, intermittent progress reports must demonstrate that the individual is making functional progress. Progress reports should meet the American Speech-Language-Hearing Association (ASHA) standards, which include at a minimum:
- Start of care date;
- Time period covered by the report;
- Communication/swallowing diagnosis;
- Statement of the individual's functional communication/swallowing at the beginning of the progress report period;
- Statement of the individual's current status as compared to evaluation baseline data and the prior progress reports, including objective measures of member communication/swallowing performance in functional terms that relate to the treatment goals;
- Changes in prognosis and why;
- Changes in plan of care and why;
- Changes in goals and why;
- Consultations with other professionals or coordination of services, if applicable;
When Speech Therapy is Considered Not Medically Necessary
Speech therapy is considered not medically necessary for the following conditions or circumstances, including but not limited to:
For children with dysfluency not related to conditions described above
When speech therapy is not focused on speech (i.e. the improvement of writing skills)
For developmental articulation errors that are self-correcting, such as:
As a treatment for Alzheimer’s disease, chronic disorders of memory and/or orientation
As a treatment for psychoneurotic or psychotic conditions
As a treatment for functional dysphonia not related to an underlying medical condition
Social communication impairments not related to an underlying medical condition
When the only goal of treatment is instruction of others, professional or non-professional, in the patient’s speech therapy program
Collaboration with other professionals or with other community resources
As instruction in English phrases when the patient’s primary language is other than English
When no further functional progress is supported by treatment notes or when therapy when progress has plateaued. The treatment plan and notes must support the continued improvement of attaining the specified speech therapy goals.
Duplicate therapy when the patient is receiving both speech and occupational therapy; these therapies should provide different treatments and not duplicate the same treatment.
Services that do not require the skills of a qualified provider of SLP services including, but not limited to, the following:
- Treatments that maintain function using routine, repetitious, or reinforced procedures that are neither diagnostic nor therapeutic (for example, practicing word drills for developmental articulation errors);
- Procedures that may be carried out effectively by the individual, family, or caregivers.
Maintenance Therapy is considered not medically necessary
Maintenance therapy programs including drills, techniques, and exercises that preserve the present level of function and prevent regression of function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, and no additional goals are thought to be attainable. The treatment goals and subsequent documentation of treatment results should specifically demonstrate that speech therapy services are contributing to such improvement.
Speech therapy for delays not related to injury or illness in speech development is considered investigational for infants and children younger than 12 months of age because delays not related to injury or illness in speech development cannot be reliably diagnosed or treated in the prelingual developmental stage.
The following treatment modalities have not been shown to be effective to the requisite degree of scientific validity and are considered investigational for treatment of dysphagia:
- Deep Pharyngeal Neuromuscular Therapy (DPNS)
- Vita-Stim and similar non-specific electrical stimulation methods
- Melodic Intonation therapy Any therapy involving digital stimulation of the mouth, tongue or pharynx in patient not having a specifically diagnosed neuromuscular disorder specifically and adversely effecting swallowing.
Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, revenue codes, and/or diagnosis codes.
- 92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder individual
- 92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder group, two or more individuals
- S9152 Speech therapy, re-evaluation
- Shriberg LD, Friel-Patti S, Flipsen P Jr., Brown RL. Otitis media, fluctuant hearing loss, and speech-language outcomes: a preliminary structural equation model. J Speech Lang Hearing Res 2000 Feb;43(1):100-20.
- McCormick DP, Baldwin CD, Klecan-Akar JS, Swank PR, Johnson DL. Association of early bilateral middle ear effusion with language at age 5 years. Ambul Pediatr. 2001 Mar-Apr;1(2):87-89.
- Johnson DL, Swank PR, Owen MJ, Baldwin CD, Howie VM, McCormick DP. Effects of early middle ear effusion on child intelligence at three, five, and seven years of age. J Pediatr. Psychol. 2000 Jan-Feb;25(1):5-13.
- Abraham SS, Wallace IF, Gravel JS. Early otitis media and phonological development at age 2 years. Laryngoscope. 1996 Jun;106(6):727-32.
- Paradise JL, Dollaghan CA, Campbell TF, et al. Otitis media and tympanostomy tube insertion during the first three years of life: developmental outcomes at the age of four years. Pediatrics. 2003 Aud;112(2):265-77.
- Hyter Y, Henry J, Atchison B, SLoane M, Black-Pond C. Children affected by trauma and alcohol exposure: A profile of the Southwestern Michigan Children's Trauma Assessment Center. The ASHA Leader, 2003 Nov:6-7,14.
- Robey RR. The efficacy of treatment for aphasic persons: a meta-analysis. Brain and Language 1994; 46:582-608.
- Morris H, Ozanne A. Phonetic, phonological, and language skills of children with a cleft palate. Cleft Palate Craniofac J. 2003 Sep;40(5):460-70.
- Goorhuis-Brouwer SM, Knijff WA. Language disorders in young children: when is speech therapy recommended? Int J Pediatr Otorhinolaryngol. 2003 May; 67(5):525-9.
- Law J, Garrett A, Nye C. Speech and language therapy interventions for children with primary speech and language delay and disorder. Cochrane Database Rev. 2003;(3):CD004110.
- Agency for Health Care Policy and Research (AHCPR). Criteria for determining disability in speech-language disorders. Updated 2004 Aug. Available at URL address:http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1.chapter.76986
- American Cleft Palate-Craniofacial Association. Parameters for evaluation and treatment ofpatients with cleft lip/palate or other craniofacial anomalies. Chapel Hill (NC): American CleftPalate-Craniofacial Association; 2000 Apr.Reviewed2005.
- Kelly H, Brady MC, Enderby P. Speech and language therapy for aphasia following stroke. Cochrane Data base Syst Rev. 2010 May 12; 5: CD000425.
- American Speech-Language-Hearing AssociationExternal Site. Typical speech and language development.
- National Dissemination Center for Children with DisabilitiesExternal Site. Speech and language impairments.
March 2016 - Annual Review, Policy Revised
March 2015 - Annual Review, Policy Revised
March 2014 - Annual Review, Policy Renewed
April 2013 - Annual Review, Policy Renewed
August 2012 - Interim Review, Policy Revised
April 2012 - Annual Review, Policy Renewed
June 2011 - Annual Review, Policy Renewed
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.