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MP 8.03.04 Speech Therapy

Medical Policy
Section
Therapy
Original Policy Date
7/31/96
Last Review Status/Date
Reviewed by consensus/4:2003
Issue
4:2003
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Speech therapy is the treatment of communication impairment and swallowing disorders. Speech therapy services facilitate the development and maintenance of human communication and swallowing through assessment, diagnosis, and rehabilitation.


Policy

Speech therapy services are considered medically necessary when used in the treatment of communication impairment or swallowing disorders due to disease, trauma, congenital anomalies, or prior therapeutic intervention.

Speech therapy services are considered investigational for dysfunctions that are self-correcting, such as language therapy for young children with natural dysfluency or developmental articulation errors that are self-correcting.


Policy Guidelines

Speech therapy sessions must meet all of the following criteria:

  • treat the needs of a patient who suffers from communication impairment or swallowing disorder, due to disease, trauma, congenital anomalies, or prior therapeutic intervention;
  • 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;
  • provide specific, effective, and reasonable treatment for the patient’s diagnosis and physical condition;
  • be delivered by a qualified, licensed provider of speech therapy services. A qualified provider is one who is licensed, where required, and performs within the scope of licensure;
  • require the judgment, knowledge, and skills of a qualified provider of speech therapy services due to the complexity and sophistication of the therapy and the physical condition of the patient.


Benefit Application

BlueCard/National Account Issues

Plans may wish to review their contract language on speech therapy services to ensure that the contract language is consistent with the Plan’s medical policy on speech therapy. Often, physical, occupational, and speech therapy are provided as a separate benefit.

Many Plans have visit or dollar maximums for speech therapy services, or these services are provided as a separate contractual benefit.

Speech therapy is frequently used in school settings and in developmental learning centers. Generally, speech therapy services are not covered for the following conditions:

  • psychosocial speech delay;
  • behavioral problems;
  • attention disorders;
  • conceptual handicap;
  • mental retardation;
  • developmental delay;
  • stammering, stuttering.

Inpatient benefits are considered not medically necessary if the hospital admission is solely for the purpose of receiving speech therapy.

Sessions
 
A speech therapy session is defined as up to 1 hour of speech therapy (treatment and/or evaluation) on any given day.

Up to 3 sessions are considered medically necessary to evaluate the patient and to develop a written plan of care.

Up to 10 speech therapy sessions per year may be covered without prior authorization. All subsequent treatment is subject to individual consideration. Prior authorization is recommended to facilitate claims processing based on a review of the written plan of care.

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 will be reached;
  • the specific treatment techniques and/or exercises to be used in the treatment; and
  • the frequency and duration of the treatment.

The plan of care should be updated as the patient’s condition changes and should be recertified by a physician at least every 30 days.

Duplicate Therapy
 
Duplicate therapy is considered not medically necessary. When patients receive both occupational and speech therapy, the therapies should provide different treatments and not duplicate the same treatment. They must also have separate treatment plans and goals (see Occupational Therapy, Medical Policy No. 8.03.03 ).

Non-Skilled Services
 

Certain types of treatment do not generally require the skills of a qualified provider of speech therapy services, such as treatments that maintain function by using routine, repetitions, and reinforced procedures that are neither diagnostic nor therapeutic (e.g., practicing word drills for developmental articulation errors) or procedures that may be carried out effectively by the patient, family, or caregivers. These services are considered not medically necessary.

Maintenance Program
 

A maintenance therapy program consists of drills, techniques, and exercises that preserve the patient’s present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved and when no further functional progress is apparent or expected to occur. Benefits for the maintenance program itself are not covered.


Rationale

A search of literature was completed through the MEDLINE database for the period of January 1990 through October 1995. The search strategy focused on references containing the following Medical Subject Heading:

– Speech Therapy

Research was limited to English-language journals on humans.

See also:

 

Occupational Therapy, Medical Policy No. 8.03.03.

 

Codes

Number

Description

CPT  92507  Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual 
ICD-9 Procedure  93.72–93.75  Speech therapy code range 
ICD-9 Diagnosis  784.3  Aphasia 
  784.41–784.49  Aphonia code range 
  784.5  Other speech disturbance 
  784.69  Other symptoms involving hard/neck (code for anomia) 
  787.2  Dysphasia 
    [Note: Policy states due to disease, trauma, congenital anomalies, or prior therapeutic intervention – unable to code, nonspecific] 
HCPCS  S9128  Speech therapy, in the home, per diem 
Type of Service  Medical 
Place of Service  Inpatient
 
Outpatient
 


Index

Aphasia, speech therapy for
Language therapy (speech therapy)
Speech therapy
Swallowing disorders, speech therapy for
Therapy, speech  


Policy History

Date Action Reason
07/31/96 Add to therapy section New policy
04/15/02 Replace policy Policy reviewed without literature review; new review date only
12/17/03 Replace policy Policy reviewed by consensus without literature review; no changes in policy other than update of codes; no further review scheduled.


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