Medical Policy: 08.03.05 

Original Effective Date: June 2004 

Reviewed: March 2021 

Revised: March 2021 

 

Notice:

This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.

 

Benefit Application:

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.

 

Description:

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. Speech therapy is a term that encompasses a variety of therapies including voice therapy.

 

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 would include tablets/devices that have the ability to become non-dedicated speech and language devices after purchase.

 

Speech therapy utilizing applications or non-payable tablets/computer devices would follow the criteria below to determine if therapy is medically necessary.

 

Prior Approval:

Prior approval is required.

 

Note: Prior Approval is not needed for the initial speech therapist’s evaluation.

 

Policy:

Not a Covered Benefit

Speech therapy/voice therapy is considered not a covered benefit in the following scenarios:

  • When speech/voice therapy services are not provided by a licensed or certified speech pathologist
  • Speech/Voice therapy to treat certain developmental, learning, or communication disorders, including dysfluency not related to a specific injury, illness, or impairment that involves the mechanics of phonation, articulation, or swallowing. (e.g. stammering and stuttering).

 

Speech therapy/voice 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, articulation or deglutition (swallowing) 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 influencing the speech center
  • Structural anomalies related to cleft palate and cleft lip
  • Neuromuscular disorders such as cerebral palsy
  • Dysphagia
  • Autism Spectrum Disorders (ASD) (*Four previously separate categories of autism consolidated into one umbrella diagnosis of “autism spectrum disorder.” (ASD) with the latest DSM update. The previous categories were: Autistic disorder, Asperger syndrome, Childhood disintegrative disorder, and Pervasive developmental disorder-not otherwise specified (PDD-NOS)).
  • Speech therapy for developmental disorders must require the need of a therapist. For example: Word drills, work on communication boards, interaction with electronic communication boards/tablets or applications, 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. If the therapy can be performed at home, without a therapist then there is not a medical necessity for formalized speech therapy.  
  • 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)

 

Indications for which voice therapy services may be considered medically necessary include, but may not be limited to:

  • anatomic abnormality
  • neurological condition
  • injury (e.g., vocal nodules or polyps, vocal cord paresis or paralysis, paradoxical vocal cord motion) 
  • or after vocal cord surgery

 

There should be the expectation by the provider that there will be significant improvement with 6 months of voice therapy. This shall be reflected in goals and treatment plan.Vocal cord health and function need to be documented by direct viewing of the patient’s vocal fold and evidenced in documentation. 

 

Documentation Requirements in a Voice Evaluation

  1. Voice exam: The following components of the voice exam need to be included:
    1. Documentation of health and function of the vocal cords
    2. Method of viewing vocal cords (videostroboscopy, Flexible laryngoscopy, etc)
    3. Diagnosis from viewing: vocal nodules, hyperfunction, muscle tension dysphonia, etc
  2. Voice Evaluation: The following elements of voice evaluation should be documented:
    1. Pitch
    2. Loudness
    3. Quality
    4. Breath Support
    5. Respiration

 

Indications for which speech therapy/voice therapy services may be considered not medically necessary include, but may not be limited to:

  • As a treatment of Alzheimer’s disease, and other chronic disorders of memory and/or orientation
  • When the goal of treatment is instruction of others, professional or non-professional, in the patient’s speech therapy program
  • When no further functional progress is supported by treatment notes or when therapy progress has plateaued
  • As a treatment for Gender dysphoria
  • When speech therapy is focused on academic areas such as reading and writing
  • Use of non-specific electrical stimulation methods for dysphagia (e.g., Deep Pharyngeal Neuromuscular Therapy (DPNS), Vita -Stim)
  • Fully computerized or Artificial Intelligence (AI) Speech Therapy 

 

Required Documentation

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 (or equivalent) 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 (or equivalent) 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).

 

If there is an inability to use standardized testing: there is an expectation that the use of non-standardized testing that can evaluate normative development status and can quantify the extent of language/speech impairment, performance deviation, or pragmatic skill deficits. A description of functional receptive and expressive language skills should be utilized to demonstrate medical necessity of therapy.

 

The following may be used as standardized Testing for Traumatic Brain Injury (TBI) amd Cognition/Aphasia

  • Repeatable battery for the assessment of neurological status (RBANS)
  • Cognitive Language Quick Test (CLQT)
  • Scales of Cognitive and Communication Abilities for Neurorehabillitation (SCCAN)
  • Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES)
  • Scales of Cognitive Ability for Traumatic Brain Injury
  • Ross Information Processing Assessment (RIPA)

 

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.

 

Screening instruments used to verify deficits after traumatic brain injury (TBI) may be used as an additional measure to quantify assessment but would not qualify as standardized testing independent of additional testing. These may include:

  • Sport concussion assessment tool (SCAT)
  • St. Louis University mental status (SLUMS)
  • Montreal cognitive assessment (MoCA)
  • Mini mental state examination (Mini Mental) 
     

 

Progress Reports

In order to reflect that continued services are medically necessary, intermittent progress reports (at a minimum the below information should be included with each request for continued therapy) 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;
  • Completion of annual standardized testing should correlate to current goals (i.e. If the plan of care includes goals for articulation, standardized testing results for articulation would be expected)

 

Policy Guidelines

Definitions

Aphasia: This disorder involves the expression of language, the comprehension of language, or both. It can be classified into specific syndromes according to the ability to produce, understand and repeat language. The ability to produce language is assessed in terms of fluency, which is defined as the rate of speech and amount of effort in producing speech. There are several syndromes of aphasia and each is associated with a particular set of language capabilities and disabilities. Global aphasia is when both expressive and receptive problems are present. These include:

  • Broca’s: This syndrome is characterized with nonfluent speech, intact comprehension and poor repetition skills.
  • Wernicke’s: This syndrome is characterized with fluent speech, poor comprehension and poor repetition skills.
  • Conduction: This syndrome is characterized by fluent speech, intact comprehension and poor repetition skills.
  • Transcortical motor: This syndrome is characterized with nonfluent speech, intact comprehension and intact repetition skills.
  • Transcortical sensory: This syndrome is characterized by fluent speech, poor comprehension and intact repetition skills.
  • Anomic: This syndrome is characterized fluent speech, and intact comprehension and repetition skills.

 

Aphonia: This is the total loss of speech sounds.

 

Apraxia/dyspraxia: This is the inability or difficulty to form words or speak, despite the ability to use the oral and facial muscles to make sounds.

 

Dysarthria: With this impairment, there is an impairment or clumsiness in the uttering of words due to diseases that affect the oral, lingual or pharyngeal muscles; speech may be difficult to understand, but the ability to communicate is present.

 

Dysphasia: impairment of speech resulting from a brain lesion, stroke or neurodevelopmental disorder

 

Stuttering: disruption in the fluency of speech; affected persons repeat letters or syllables, pause or hesitate abnormally, or fragment words when attempting to speak.

 

Voice Therapy: A subset of speech therapy, the intervention is conducted to achieve improved voice production and coordination of respiration and laryngeal valving.

Standardized Tests of Overall Receptive/Expressive Language Skills:

Clinical Evaluation of Language Fundamentals (CELF-5)
Ages Covered Normal Range of Standard Scores Reported As
5-21 years 85-115 Core Language Score
Receptive Language
Expressive Language
Note: Individual subtests are reported as scaled scores. Need to report “Composite Scores” as listed above.

 

Clinical Evaluation of Language Fundamentals Preschool (CELF-P)
Ages Covered Normal Range of Standard Scores Reported As
3-6 years 85-115 Core Language score
Receptive Language Index 
Expressive Language Index 
Note: Individual subtests are reported as scaled scores. Need to report “Index Scores”

 

Oral and Written Language Scales (OWLS)
Ages Covered Normal Range of Standard Scores Reported As
3-21 years 85-115 Listening ComprehensionOral Expression
Note: Provides Age Equivalent score for both Listening Comprehension and Oral Expression

 

Preschool Language Scale-5 (PLS-5)
Ages Covered Normal Range of Standard Scores Reported As
0-7 85-115 Total LanguageAuditory Comprehension
Expressive Communication
Note: Provides Age Equivalent scores for both Auditory Comprehension and Expressive Communication

 

Clinical Evaluation of Language Fundamentals (CASL)
Ages Covered Normal Range of Standard Scores Reported As
3-21 85-115 Receptive Language Index
Expressive Language Index
Note: Individual subtests are reported as scaled scores. Need to report “Index Scores” as noted above

 

Test of Early Language Development-4 (TELD-4)
Ages Covered Normal Range of Standard Scores Reported As
3-7 years 85-115 Receptive Language Index 
Expressive Language Index
Note: Individual subtests are reported as scaled scores. Need to report “Index Scores” as noted above

 

Criterion Reference Tests of Overall Receptive/Expressive Language Skills:

Receptive-Expressive Emergent Language Test (REEL)
Ages Covered Normal Range of Standard Scores Reported As
0-3 years 90-110 Receptive Language Ability Score
Expressive Language Ability Score
Note: Age equivalent scores are also provided for Receptive and Expressive Language

 

Rosetti Infant Toddler Language Scales
Ages Covered Normal Range of Standard Scores Reported As
0-3 years Not reported by Standard scores Basal and Ceiling Age Equivalent scores for:
Interaction Attachment
Pragmatics
Gesture
Play
*Language Comprehension
*Language Expression
Note: Will list each basal and ceiling age equivalent as a range such as Basal 0-3 months; Ceiling 16-18 months. Only needed age equivalents are for Language Comprehension and Language Expression

 

Test of Early Communication and Emerging Language (TECEL)
Ages Covered Normal Range of Standard Scores Reported As
All Ages 90-110 Communicative Ability Index
(Encompasses receptive and expressive language skills)
Note: A single age equivalent is provided for “Overall” receptive/expressive language skills

 

Functional Communication Profile
Ages Covered Normal Range of Standard Scores Reported As
3 years through Adult None provided Only narrative information is provided and severity levels as:
Mild, Moderate, Severe, Profound
Note: yields an overall inventory of an individual’s communication abilities, mode of communication (e.g., verbal, sign, nonverbal, augmentative), and degree of independence.

 

Standardized Tests for Articulation:

Goldman Fristoe Test of Articulation (GFTA)
Ages Covered Normal Range of Standard Scores Reported As
2-6 through 21-0 85-115 Standard Score
Age Equivalent Score
Note: None

 

Photo Articulation Test (PAT)
Ages Covered Normal Range of Standard Scores Reported As
3-0 through 8-11 85-115 Standard Score
Age Equivalent Score
Note: None

 

Clinical Assessment of Articulation and Phonology (CAAP)
Ages Covered Normal Range of Standard Scores Reported As
2-6 through 11-11 85-115 Standard Score
Age Equivalent Score
Note: None

 

Standardized Tests for Pragmatic Language Skills:

Test of Pragmatic Language (TOPL)
Ages Covered Normal Range of Standard Scores Reported As
6-0 through 18-11 85-115 Pragmatic Language Usage
Index
Age Equivalent Score
Note: None

 

Clinical Assessment of Pragmatics (CAPS)
Ages Covered Normal Range of Standard Scores Reported As
7-0 through 18-0 85-115 Core Pragmatic Language
Composite
Note: Individual subtests are reported as scaled scores. Need to report “Composite score” as noted above. There is no Age Equivalent score for this assessment.

 

Standardized Tests for Aphasia:

Boston Naming
Ages Covered Normal Range Reported As
18-79 90-100% Percentage

 

Boston Diagnostic Aphasia Exam
Ages Covered Normal Range Reported As
18-79 90-100% is WNL Percentages in categories of Auditory Comprehension, Oral Expression, Understanding Written Language 
Note: Individual subtests are within categories and can show deficits

 

Western Aphasia Battery
Ages Covered Normal Range of Standard Scores Reported As
18-89 0-25 Very Severe
26-50 Severe
51-75 Moderate
76 and up Mild
Severity Rates

 

Assessment of Language-Related Functional Activities (ALFA)
Ages Covered Normal Range Reported As
16-95 90-100% is WNL
Or
Independent Functioning Rating of:
1=WNL
2=some need for assistance
3=not able to complete task without assistance
Percentages in subtests
Or
Functioning Rates

 

Standardized Tests for TBI/Post Concussion/Cognition:

Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)
Ages Covered Normal Range of Standard Scores Reported As
12-89 85-115 Overall Total Ability Score
Or
Immediate Memory
Visuospatial/Constructional
Language
Attention
Delayed Memory
Note: Can provide total scale score or individual subtest scores

 

Cognitive Language Quick Test (CLQT)
Ages Covered Normal Range of Standard Scores Reported As
18-89 4.0-3.5=WNL Composite Severity Rating of:
WNL, Mild, Moderate, Severe

 

Scales of Cognitive and Communication Abilities for Neurorehabilitation (SCCAN)
Ages Covered Normal Range of Standard Scores Reported As
18-91 Raw Score of 87-94 SCCAN Degree of Severity:
Typical Functioning, Mild, Moderate, Severe

 

Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES)
Ages Covered Normal Range of Standard Scores Reported As
18-79 85-115 Three types of scores are gathered for each subtest: time, accuracy and reasons.
  • Plan an Event
  • Schedule a Work day
  • Decide on a Gift
  • Build a Case to Solve a Common Problem

 

Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI)
Ages Covered Normal Range of Standard Scores Reported As
15 and older 130 WNL
115-130 Borderline
110-115 Mild
Standard Score

 

Ross Information Processing Assessment-2 or Geriatric
Ages Covered Range of Standard Scores/Percentages Reported As
15 and up 14-20 Mild 90-100%
11-13 Moderate 60-90%
8-10 Marked 30-60%
1-7 Severe 0-30%
Subtests: Immediate Memory; Recent Memory; Temporal Orientation (Recent Memory); Temporal Orientation (Remote Memory; Spatial Orientation; Orientation to Environment;  Recall of General Information; Problem Solving and Abstract Reasoning; Organization; Auditory Processing and Retention
Note: Can be reported as percentages or standard score

 

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

 

Selected References:

  • American Speech-Language-Hearing Association Typical speech and language development.
  • National Dissemination Center for Children with Disabilities Speech and language impairments.
  • C. H. Yang, P. H. Chang, K. L. Lin and K. S. Cheng, "Outcomes comparison between smartphone based self-learning and traditional speech therapy for naming practice," 2016 International Conference on System Science and Engineering (ICSSE), Puli, 2016, pp. 1-4.doi: 10.1109/ICSSE.2016.7551624
  • Law, J., Dennis, J. Speech and language therapy interventions for children with primary speech and/or language disorders.  Cochrane Database of Systematic Reviews, 2017 (1) DOI: 10.1002/14651858.CD012490.
  • Morgan A, Ttofari Eecen K, Pezic A, et al. Who to Refer for Speech Therapy at 4 Years of Age Versus Who to "Watch and Wait"? J Pediatr 2017; 185:200.
  • Efstratiadou, E. A., Papathanasiou, I., et al. (2018). Journal of Speech, Language, and Hearing Research, 1-18. Epub ahead of print retrieved April 27, 2018 
  • Figueiredo IC, Vendramini SHF, Lourenção LG, Sasaki NSGMDS, Maniglia JV, Padovani Junior JA, Raposo LS, Santos MLSG. Profile and speech-language rehabilitation of patients with laryngeal cancer. Codas. 2019 Mar 7;31(1)
  • Pennington L, Stamp E, Smith J, Kelly H, Parker N, Stockwell K, Aluko P, Othman M, Brittain K, Vale L. Internet delivery of intensive speech and language therapy for children with cerebral palsy: a pilot randomised controlled trial. BMJ Open. 2019 Jan 30;9(1):e024233. doi: 10.1136/bmjopen-2018-024233.
  • Stahl B, Mohr B, Büscher V, Dreyer FR, Lucchese G, Pulvermüller F. Efficacy of intensive aphasia therapy in patients with chronic stroke: a randomised controlled trial. J Neurol Neurosurg Psychiatry. 2018 Jun;89(6):586-592. doi: 10.1136/jnnp-2017-315962. Epub 2017 Dec 22.
  • Morgan A, Ttofari Eecen K, Pezic A, et al. Who to Refer for Speech Therapy at 4 Years of Age Versus Who to "Watch and Wait"? J Pediatr 2017; 185:200.
  • Simms MD. Language Development and Communication Disorders. In: Kliegman RM, St Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM editors. Nelson textbook of pediatrics, 21st ed. Philadelphia, PA; Saunders, 2020.
  • LeBorgne WD, Donahue EN. Voice therapy as primary treatment of vocal fold pathology. Otolaryngol Clin North Am. 2019 May 13 [Epub ahead of print]
  • Tibbetts KM, Dominguez LM, Simpson CB. Impact of perioperative voice therapy on outcomes in the surgical management of vocal fold cysts. J Voice. 2018;32(3):347-351.
  • Barcelos CB, Silveira PAL, Guedes RLV, et al. Multidimensional effects of voice therapy in patients affected by unilateral vocal fold paralysis due to cancer. Braz J Otorhinolaryngol. 2018;84(5):620-629.
  • Yiu EM, Lo MC, Barrett EA. A systematic review of resonant voice therapy. Int J Speech Lang Pathol. 2017;19(1):17-29.
  • Palmer R, Dimairo M, Latimer N, Cross E, Brady M, Enderby P, et al. Computerised speech and language therapy or attention control added to usual care for people with long-term post-stroke aphasia: the Big CACTUS three-arm RCT. Health Technol Assess 2020;24(19)

 

Policy History:

  • March 2021 - Annual Review, Policy Revised
  • March 2020 - Annual Review, Policy Revised
  • March 2019 - Annual Review, Policy Revised
  • March 2018 - Annual Review, Policy Revised
  • March 2017 - Annual Review, Policy Revised
  • July 2016 - Interim Review, Policy Revised
  • 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.

 

*CPT® is a registered trademark of the American Medical Association.