Speech therapy is the treatment of communication impairment and swallowing disorders. Speech therapy services involve the use of special techniques to facilitate the development and maintenance of human verbal communication and swallowing through patient assessment, diagnosis, and rehabilitation. When speech pathology is a benefit, the following guidelines apply. Payment may be made for speech therapy services when ordered by a physician and performed by a licensed or otherwise certified speech pathologist/therapist. Speech therapy services must be directed to the active treatment of at least one of the following conditions:
- Disease (e.g., post-cerebrovascular accident, apraxia);
- Trauma (e.g., subdural hematoma influencing the speech center);
- Congenital anomalies (defects which are the result of imperfect development of an embryo or established during intrauterine life, e.g., cleft palate and lip);
- Previous therapeutic processes (e.g., esophageal training following laryngectomy);
- Medical/biological voice dysfunctions associated with vocal cord lesions.
Some examples of conditions for which voice therapy is eligible include:closed head trauma (850)
laryngeal trauma and trauma related dysphonias (959.0)
polyps (478.4)
vocal cord lesions (478.4)
vocal cord paralysis or paresis (478.3-478.34)
vocal cysts (478.79)
vocal nodules (478.79) NOTE: Voice therapy provided prior to surgery is not a covered service. Speech therapy services are generally medically appropriate for patients diagnosed with the conditions indicated above from the age 18 months through adulthood. Additionally, speech therapy services must achieve a specific diagnosis-related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time. These services must also provide specific, effective, and reasonable treatment for the patient's diagnosis and physical condition. Speech therapy should be limited to 16 sessions per 365-day period. (Number of sessions could vary per group.) Up to three sessions are considered medically necessary to evaluate the patient and to develop a written plan of care. Ten additional speech therapy sessions per year are generally reasonable and necessary for the treatment of covered conditions. Up to three additional sessions are considered eligible for coverage to establish a speech therapy maintenance program, after some or all of the goals of therapy have been reached. NOTE: The maintenance program itself is not eligible for coverage. Coverage for speech therapy services in excess of 16 sessions per year should be determined on an individual consideration basis using the documented plan of care. The plan of care should include:
- Specific statements of long- and short-term goals;
- Measurable objectives;
- A reasonable estimate of when the goals of therapy will be reached;
- A description of the specific treatment techniques and/or exercises to be used in the treatment;
- The frequency and duration of the treatment.
Speech therapy services are generally not medically appropriate treatment for the following conditions:
- Psychosocial speech delay
- Behavior problems (including impulsive behavior and impulsivity syndrome)
- Mental retardation
- Developmental delay
- Stuttering and stammering
Additionally, coverage for in-patient services is not available if speech therapy was the sole reason for the hospitalization.Effective for services performed on or after June 20, 1994, services performed by a speech therapist/pathologist that are within their scope of licensure and meet the coverage criteria indicated above, are eligible for payment. The following are coverage and patient selection criteria for patients exhibiting developmental delay in speech or language articulation and/or neurological disorders which impact speech:
- Speech therapy services provided for patients with delayed speech/language development are generally medically necessary when the delay is secondary to a history of significant chronic ear infection or loss of hearing during the formative period for speech and language skills. Generally, this period is considered to be from birth to 12 years of age. The majority of these patients will fall within an age range of 18 months to 8 years.
- Chronic ear infections must be of such documented severity and duration that the development of speech/language skills can be shown to be impaired. Generally, a bilateral hearing loss of 40dB of sufficient length (generally 3 months) during the speech/language formative period is adequate for the coverage of these services.
- A diagnosis of acute or chronic otitis media by itself is not a sufficient diagnosis to substantiate coverage for speech therapy services. An observed and documented delay in or loss of speech/language skills must occur to warrant coverage of these services.
- For patients with chronic otitis media, the number of infections is not as important as the duration and timing of a related hearing loss when determining coverage for speech therapy. Likewise, the presence or absence of ear tubes should not generally impact the coverage determination for speech therapy services. Coverage should generally be dependent on the degree of articulatory disturbance rather than the presence or absence of ear tubes or frequent ear infection.
- The frequency and duration of services normally needed to treat these conditions will vary considerably based on many factors, including the age of the patient, learning capabilities, severity of the problem, or other medical complications. In general, a therapist needs approximately 2 to 3 months, with therapy scheduled 1 to 3 times per week, to reach some or all of the goals of therapy.
- A sole diagnosis of developmental delay is not generally adequate to establish coverage for speech therapy services. Additionally, speech therapy is not considered medically necessary for patients diagnosed with psychosocial speech delay, behavior problems, including impulsive behavior or impulsivity syndrome, attention disorders (e.g., A.D.D.), or conceptual handicap.
- Patients diagnosed with one of the various forms of mental retardation, Down's Syndrome, or autism, are not generally considered to be good candidates for speech therapy services. These patients can receive the needed speech therapy and developmental services in a school setting or through special developmental learning centers. However, in some cases these patients with speech impairments can benefit from speech therapy as long as there remains sufficient documented functional and biological capacity to indicate a positive prognosis for the patient receiving these services.
- NOTE:
- For information on cognitive rehabilitation and sensory integration techniques, refer to HMPB Y-2.
- NOTE:
- This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
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