Medical Policies Online - Policy #: 10.06.01d

Medical Policy Bulletin

Title:

Outpatient Speech Therapy

Policy #:

10.06.01d

The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin 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 Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the Company's coverage positions for outpatient speech therapy services, including VitalStim� therapy and myofunctional therapy.

The provision of benefits for all services related to outpatient speech therapy is in accordance with the individual's benefit contract and varies by product and group. Therefore, individual member benefits must be verified. Some services may be subject to state mandates, medical necessity criteria, coverage limits, precertification or preapproval, or existing contractual exclusions. Refer to the Cross References section in this policy for a list of policies that address services related to this topic, as well as links to summaries of any applicable mandate(s).

For information on speech therapy services for individuals with autism spectrum disorder (ASD), please refer to the Company's policy on the medical evaluation and management of autism spectrum disorders.

Description:

Speech/language pathology services are services that are deemed necessary for the diagnosis and/or treatment of speech disorders, language disorders, and cognitive communication impairments, which result in communication disabilities, or dysphagia (swallowing disorder). Speech therapy is the medically prescribed treatment for speech and language disorders due to disease, surgery, injury, congenital anomalies (eg, congenital hearing impairment), speech/language delay, or previous therapeutic processes that result in communication disabilities and/or dysphagia.

VitalStim� Experia (VitalStim�) is an electrotherapy treatment that is used by licensed health care providers, including speech therapists, for treating individuals who have dysphagia caused by any non-mechanical cause. VitalStim� therapy is a specialized type of neuromuscular electrical stimulation (NMES) in which a small current is passed through external electrodes on the neck to stimulate inactive or atrophied swallowing muscles. With repeated therapy, throat muscles are said to be retrained. However, based upon review of the scientific and clinical literature, the clinical efficacy and utility of this service remains unproven.

Myofunctional therapy (or, orofacial myology) is the treatment of an orofacial muscle imbalance, an incorrect swallowing pattern, temporomandibular joint muscle dysfunction syndrome, and/or tongue thrusting, bruxing, clenching, or sucking habits. Oral myofunctional therapy uses exercises and stimulation to increase awareness of oral and facial muscles and inhibit inappropriate oral behaviors and/or strengthen appropriate oral muscle functioning. However, based upon review of the scientific and clinical literature, the clinical efficacy and utility of this service remains unproven.

Policy

MEDICAL NECESSITY CRITERIA

Speech pathology evaluation and services related to speech therapy that are within the scope of the member's benefit contract are considered medically necessary and, therefore, covered when all of the following criteria are met:

The evaluation (92506) is prescribed by a physician and performed by a speech/language pathologist who is licensed in the state where the services are being performed and who is certified by the American Speech-Language-Hearing Association (ASHA).
- The documentation submitted must include a current comprehensive diagnostic evaluation that was performed within three months of the requested start date of the therapy.
The services must be of such a complex nature that they can only be performed by a speech/language pathologist.
The medical condition must be such that there is a reasonable expectation that the services will bring about a significant improvement within a reasonable time frame, regardless of whether the individual has a coexisting disorder.
The services are provided in accordance with an ongoing plan of care specific to the diagnosis.
- The plan of care should incorporate ongoing care and be updated�at least weekly, or more frequently as treatment progresses and goals change or are met.�Upon request, documentation�must be made available to the Company to show measurable progress toward meeting the short- and long-term goals outlined in the plan of care.
- The therapy is performed for a communication disorder that is a result of at least one of the following:
  - Disease (eg, Parkinson's disease resulting in increased difficulty in swallowing and speaking)
  - Surgery (eg, surgical removal of a malignant growth on the head or neck)
  - Injury (eg, automobile accident resulting in a subdural hematoma influencing the speech center causing neurogenic stuttering; aphasia following a cerebrovascular accident [CVA])
  - Congenital anomalies (eg, inborn defect of the skull, cleft lip, cleft palate, congenital hearing impairment)
  - Speech/language delay that is developmental in nature (ie, Speech and/or language skills are below the normal range of developmental milestones for the age of the individual as determined by age-appropriate standardized test data.)
The amount, frequency, and duration of the services must be consistent with accepted standards of practice.
Continuous assessment of the individual's progress is a component of ongoing therapy services and is not a re-evaluation.
- A re-evaluation (S9152) is the reassessment of the individual’s performance and goals, after a plan of care has been instituted. A re-evaluation is considered medically necessary and, therefore, covered when a significant improvement, decline, or change in the individual's condition occurs, or if it is requested by the Company to determine the medical necessity of ongoing intervention.
OR
The evaluation (assessment) (92610) and therapy is performed for a swallowing disorder (dysphagia) resulting from a condition such as, but not limited to, a CVA regardless of whether a communication disorder also exists.

Speech therapy services performed for reasons other than those listed above are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis or treatment of illness or injury.

CONDITIONS THAT DO NOT MEET MEDICAL NECESSITY CRITERIA

Conditions or situations that do not meet medical necessity criteria for speech pathology evaluation and services related to speech therapy include, but are not limited to:

Psychosocial speech delay (Psychosocial factors can be associated with delayed speech development. These factors include, eg, large family size, late birth order, twinship, bilingual background.)
Behavior/social problems (eg, impulsive behavior, difficulty in initiating/maintaining a conversation)
Stammering and stuttering that was not caused by acquired brain damage
Programs that are primarily educational in nature or that support an academic program
Speech therapy for the maintenance of a chronic condition
- Maintenance therapy is defined as a continuation of care and management of the individual when the maximum therapeutic value of a treatment plan has been achieved, no additional functional improvement is apparent or expected to occur, and the provision of services for a condition ceases to be of therapeutic value
Services that otherwise would not require the skills of a qualified speech/language pathologist, such as treatments that maintain function by using routines and repetitions
- Examples of these services include, but are not limited to, word drills for developmental articulation errors, computer-based programs (eg, Fast Forward�), and procedures that may be performed by the individual, family, or caregivers.

MYOFUNCTIONAL THERAPY (OROFACIAL MYOLOGY)

Myofunctional therapy (orofacial myology) is considered experimental/investigational and, therefore, not covered because the safety and/or efficacy of this service cannot be established by review of the available published peer-reviewed literature.

VITALSTIM� EXPERIA (VITALSTIM�)

The use of VitalStim� for the treatment of dysphagia is considered experimental/investigational and, therefore, not covered because the safety and/or efficacy of this service cannot be established by review of the available published peer-reviewed literature.

SPEECH-GENERATING DEVICES, INCLUDING COMPUTER-BASED PROGRAMS

Speech therapy provided in association with a speech-generating device, including a computer-based program, is considered medically necessary and, therefore, covered when the device is considered medically necessary in accordance with the terms defined in the applicable medical policy on this topic.

Electronic speech devices that are designed to improve fluency problems (such as stuttering) rather than to aid in communication disabilities are considered experimental/investigational and, therefore, not covered as the safety and/or efficacy of these devices cannot be established by review of the available published peer-reviewed literature. Examples of these types of electronic devices include, but are not limited to:

SpeechEasy
FluencyMaster

DUPLICATE THERAPY

When individuals are receiving both occupational and speech therapy, or speech therapy with different providers, the therapies must provide different treatments with separate treatment plans and goals in order for each to be covered and be separately reimbursed. Otherwise, the therapy is considered duplicate therapy, and coverage and reimbursement is only available for one therapy.

BENEFIT LIMITATIONS

Limitations, frequency, and annual maximums may be applied and vary by product or by group.
Individual member benefits must be verified, as outpatient speech therapy benefits vary by product and group.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BILLING GUIDELINES

Speech therapy sessions are service-based codes, not time-based codes. Therefore, these services are reported and reimbursed based on the service provided, not the duration of the service. Providers should report a single encounter with "1" as the unit of service, regardless of the duration of the service on a given day.
CAPITATION

In geographic regions with a capitated outpatient rehabilitation program, outpatient speech therapy services are not included in capitation.

This policy is consistent with applicable state mandates. The laws of the state where the group benefit contract is issued determine the mandated coverage.

Outpatient speech therapy services may be available for coverage in accordance with the New Jersey State Mandate for Biologically-Based Mental Illness and the Pennsylvania State Mandate for Autism Spectrum Disorders (ASD).

MEDICARE

References

Cantwell DP, Baker L. Assessment. In: Developmental Speech and Language Disorders. New York, NY: Guilford Press; 1987: 42.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 170.3: Speech-language pathology services for the treatment of dysphagia. [CMS Web site]. 10/01/06. Available at: http://www.cms.hhs.gov/mcd/cpt_license.asp?type=ncd&page=results.asp&ncd_id=170.3&ncd_version=2&basket=ncd:170.3:2:Speech%2DLanguage+Pathology+Services+for+the+Treatment+of+Dysphagia. Accessed July 10, 2009.

Christensen M, Hanson M. An investigation of the efficacy of oral myofunctional therapy as a precursor to articulation therapy for pre-first grade children. J Speech Hear Disord.1981;46(2):160-165.

Company benefit contracts.

Forrest K. Are oral-motor exercises useful in the treatment of phonological/articulatory disorders. Semin Speech Lang. 2002;23(1):15-26.

The General Assembly of Pennsylvania. House bill no. 1150. [State of Pennsylvania Web site]. 07/01/08. Available at:http://www.legis.state.pa.us/cfdocs/legis/PN/Public/btCheck.cfm?txtType=HTM&sessYr=2007&sessInd=0&billBody=H&billTyp=B&billNbr=1150&pn=4133. Accessed July 10, 2009.

Hauner KKY, Shriberg LD, Kwiatkowski J, Allen CT. A subtype of speech delay associated with developmental psychosocial involvement. J Speech, Lang, Hear Res. 2005;48(3):635-650. Also available on the Journal of Speech, Language, and Hearing Research Web site at: http://jslhr.asha.org/cgi/content/abstract/48/3/635. Accessed October 1, 2009.

Highmark Medicare Services. Local Coverage Determination (LCD).L27531: Speech-language pathology (SLP) services: communication disorders. [Highmark Medicare Services Web site]. Original: 07/11/08. (Revised: 12/12/08). Available at: http://www.highmarkmedicareservices.com/policy/mac-ab/l27531-r4.html. Accessed July 10, 2009.

Highmark Medicare Services. Local Coverage Determination (LCD).L27537: Speech-language pathology (SLP) services: dysphagia; includes VitalStim� therapy. [Highmark Medicare Services Web site]. Original: 07/11/08. (Revised: 12/12/08). Available at: http://www.highmarkmedicareservices.com/policy/mac-ab/l27537-r4.html. Accessed July 10, 2009.

Kiger M, Brown CS, Watkins L. Dysphagia management: an analysis of patient outcomes using VitalStim therapy compared to traditional swallow therapy. Dysphagia. 2006;21(4):243-253.

Nam-Jong P. Dysphagia. [e-Medicine Web Site]. 06/25/08. Available at: http://www.emedicine.com/pmr/topic194.htm. Accessed July 9, 2009.

New Jersey Annotated Statutes. Title 17 Corporations and institutions for finance and insurance. Subtitle 3: Insurance. Part 9: Hospital and medical service corporations, etc. Chapter 48E: Health service corporations. Coverage for audiology and speech-language pathology services. West Group. 2002. Current through L.2002, c.44. 17:48E-35.17.

New Jersey Permanent Statutes. Title 17B Insurance. 17B:26-2.1p Health insurance policy to cover certain audiology, speech-language pathology services. L.1997, c.419, s.4.

New Jersey Permanent Statutes. Title 17B Insurance. 17B:27-46.1s. Group health insurer to cover certain audiology, speech-language pathology services. L.1997, c.419, s.5.

Ray, J. Functional outcomes of orofacial myofunctional therapy in children with cerebral palsy. Int J Orofacial Myology. 2001;27:5-17.

Shaw GY, Sechtem PR, Searl J, et al. Transcutaneous neuromuscular electrical stimulation (VitalStim) curative therapy for severe dysphagia: myth or reality? Ann Otol Rhinol Laryngol. 2007;116(1):36-44.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. VitalStim� Experia. 510(k) summary. [FDA Web site]. 06/11/07. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf7/K070425.pdf. Accessed July 9, 2009.

VitalStim� Therapy. What is VitalStim� Therapy? [VitalStim� Therapy Web site]. Available at:
http://www.vitalstim.com/what_is_vitalstim/index.aspx?id=148. Accessed July 9, 2009.

Wang JM. Causes of speech delay in children - brief article from Family Practice News. [Business Wire (BNET) Web site.] 05/15/2000. Available at: http://findarticles.com/p/articles/mi_7342/is_10_30/ai_63566882/. Accessed October 1, 2009.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	92506, 92507, 92508, 92526, 92610
ICD Procedure	N/A
ICD Diagnosis	Report any applicable diagnosis that meets the medical necessity criteria in this policy.
HCPCS Level II	S9152: Speech therapy, re-evaluation
Modifier(s)	N/A
Revenue Codes	440: General classification for speech-language pathology 441: Speech-language pathology charge by visit 442: Speech-language pathology hourly charge 443: Speech-language pathology group rate 444: Speech-language pathology evaluation or re-evaluation 449: Other speech-language pathology services 979: Professional fees - speech pathology

Cross References

Associated attachments to Policy 10.06.01d: Outpatient Speech Therapy

	Attachment A : Outpatient Speech Therapy Description: Communicates the New Jersey state mandate by the Department of Banking and Insurance for biologically-based mental illness (BBMI) regulations in regard to outpatient speech therapy
	Attachment B: Outpatient Speech Therapy Description: New Jersey mandate information on autism spectrum disorder or another developmental disability
	Attachment C: Outpatient Speech Therapy Description: Provides a summary of the Pennsylvania State Mandate for autism spectrum disorders (ASD)

Cross Reference Policies

00.03.03c:

Outpatient Short-Term Rehabilitation Services Included in Capitation

02.01.01a:Home Health Care Services

05.00.21f:Durable Medical Equipment (DME)

05.00.23b:Electronic Speech Aids

05.00.32b:Speech- and Non-Speech-Generating Devices

05.00.49a:Hearing Aid Devices, Testing, Fittings, and Accessories

07.03.07e:Evaluation and Management of Autism Spectrum Disorders (ASD)

11.01.02i:Cochlear Implant

Version Effective Date: 11/13/2009