Speech Therapy*

Medical Policy: 08.03.05
Original Effective Date: June 2004
Reviewed: February 2008
Revised: February 2007

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

Description:

Speech therapy is the treatment of communication impairments and swallowing disorders. Speech therapy services facilitate the development and maintenance of human communication and swallowing through assessment, diagnosis, and rehabilitation. Speech therapists treat disorders resulting from illness, trauma, disease, or congenital anomaly including: language, speech articulation and voice disorders; oral pharyngeal dysfunction and related disorders; and cognitive/communication disorders.

Policy:

Speech therapy services may be considered medically necessary when they are related to a specific injury, illness, or disease; 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 suffers from 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.

Physical impairments for which speech therapy services may be considered medically necessary include:

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
Sensorineural hearing loss
Dysfunction occurring as a result of a therapeutic process such as vocal cord surgery, laryngectomy, radiation therapy, or ototoxic medication
Oral motor apraxia, confirmed by the following diagnostic elements:
- Standardized testing of receptive and expressive language skills
- Standardized articulation testing, including a conversational intelligibility sample
- Diadochokinetic testing
- Oral motor examination including assessment of range of motion, strength, impaired coordination, groping, and oral management of food
Hearing loss or impairment meeting all of the following criteria:
- Attributed to medically documented chronic middle ear effusion occurring during the formative years of speech (through age 3)
- No less than 3 months history of flat tympanograms or abnormal pneumatic otoscopy
- Documented hearing loss greater than or equal to 25dB in the speech range of 500-2000 Hertz

Prior approval is recommended. Submit a prior approval now.

Prior approval is not needed for the initial speech therapist's evaluation.

Recommended Documentation for Prior Approval

Minimum acceptable documentation, in the form of a speech therapy 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.
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 oral motor apraxia include complete results from diagnostic elements listed above.

Children 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.

Speech therapy is considered not medically necessary for the following conditions or circumstances:

For children with dysfluency not related to conditions described above
For developmental articulation errors that are self-correcting
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 of stuttering or stammering not related to an underlying medical condition
As a treatment for functional dysphonia
When the only goal of treatment is the 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
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.
When no further functional progress is apparent or expected to occur
Duplicate therapy when the patient is receiving both speech and occupational therapy; these therapies should provide different treatments and not duplicate the same treatment.

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Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT** codes, Alpha Numeric (HCPCS level 2) codes, revenue codes, and/or ICD-9 CM diagnostic codes.

CPT 92506 may be used to report evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status
CPT 92507 may be used to report treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); individual
CPT 92508 may be used to report treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); group, two or more individuals
CPT 92526 may be used to report treatment of swallowing dysfunction and/or oral function for feeding
CPT 92610 may be used to report evaluation of oral and pharyngeal swallowing function
G0153 may be used to report services of speech and language pathologist in the home health setting, each 15 minutes
S9152 Speech therapy, re-evaluation

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Selected References:

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.AvailableatURLaddress:http://www.guideline.gov/summary/summary.aspx?doc_id=5333&nbr=003646&string=cleft+AND+lip%2fpalate

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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:

Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Prior Approval is recommended for this policy.

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.