Medical Policy: 08.03.05 

Original Effective Date: June 2004 

Reviewed: March 2020 

Revised: March 2020 

 

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
  • 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, 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.

 

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)

  • 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.

 

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.

 

Policy History:

  • 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.