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:
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. |
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