| Utilization Management Section - Speech Therapy
| Topic: Speech Therapy (ST) |
Date of Origin: 01/1996 |
| Section: UM |
Policy No: 9 |
| Approved Date: 12/08/2009 |
Effective Date: 01/01/2010 |
| Next Review Date: 08/2010 |
|
IMPORTANT REMINDER
Regence Medical Policies are developed to provide guidance for members and providers regarding
coverage in accordance with contract terms. Benefit determinations are based in all cases on
the applicable contract language. To the extent there may be any conflict between the Medical
Policy and contract language, the contract language takes precedence.
PLEASE NOTE: Contracts exclude from coverage, among other things, services or procedures that
are considered investigational or cosmetic. Providers may bill members for services or
procedures that are considered investigational or cosmetic. Providers are encouraged to inform
members before rendering such services that the members are likely to be financially responsible
for the cost of these services.
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/Criteria
| I. |
Speech therapy
may be medically necessary when all of the
following criteria are met: |
| |
A. |
Services
are for the treatment of communication impairment
or swallowing disorders due to a covered injury,
illness or disease and are appropriate treatment
for the condition |
| |
B. |
Services
are performed to restore and improve the functional
abilities of a patient who suffers from a communication
disability or swallowing disorder due to illness,
injury, congenital anomaly or prior therapeutic
intervention |
| |
C. |
Treatments
are expected to result in significant, practical
improvement in the patient's level of functioning
in a reasonable and generally predictable period
of time or are necessary for the establishment
of a safe and effective maintenance program.
Treatments should be directed towards restoration
or compensation for lost function. The improvement
potential must be significant in relation to
the extent and duration of therapy required |
| |
D. |
Therapy
is prescribed by an eligible provider as defined
by the member contract |
| |
E. |
Therapy
is rendered by a qualified provider of speech
therapy services. A qualified provider
is one who is licensed where required and is
performing within their scope of license; e.g.,
speech pathologist, speech-language pathologist,
speech clinician |
| |
F. |
The services
must be considered under currently accepted standards
of medical practice to be a specific and effective
treatment for the patient's existing condition |
| |
G. |
The complexity
and sophistication of the therapy and the patient’s
condition must require the judgment and knowledge
of a qualified provider of speech therapy services |
| |
H. |
Services
do not duplicate those provided by any other
therapy, particularly occupational therapy. |
| |
|
|
| II. |
If the
above criteria are met, the following guidelines
apply: |
| |
The treatments
and procedures listed below require the skills
and expertise of a licensed eligible provider.
In conjunction with delivering these services,
the provider is expected to provide teaching
and training to the patient and available family
members and/or care givers to facilitate their
participation in and/or assumption of the total
speech therapy program. Maintenance programs
must be taught before the end of the active rehabilitation
program. |
| |
|
|
|
| |
A. |
Therapy
directed towards the active treatment of disease,
trauma, congenital anomalies or therapeutic
processes which result in: |
| |
|
1) |
Dysphagia - difficulty
in swallowing |
| |
|
2) |
Dysphasia - impairment
of speech consisting of a lack of coordination
and failure to arrange words in their proper
order |
| |
|
3) |
Dysarthria - impairment
of articulation |
| |
|
4) |
Aphasia - impairment
of the power of expression by speech, writing
or symbols or of comprehending spoken or written
language |
| |
|
5) |
Apraxia - the inability
to perform purposeful movement in the absence
of paralysis or other motor or sensory impairment |
| |
|
6) |
Aphonia - inability
to produce speech sounds from the larynx, due
to paralysis or disease of the pharyngeal nerves |
| |
|
|
|
| |
B. |
Children
with speech delay due to documented, acquired
hearing loss; e.g., repeated ear infections resulting
in hearing loss |
| |
C. |
Vocal
cord nodules are present and services are in
lieu of surgery |
| |
D. |
Tongue
thrust therapy if a neuromuscular disorder is
present |
| |
E. |
Paradoxical
vocal cord dysfunction - a form of laryngeal
dyskinesia characterized by inappropriate adduction
of the true vocal cords during inspiration, leading
to obstructive airway symptoms. |
| |
|
|
|
| III. |
The following
services are considered not medically necessary: |
| |
|
|
|
| |
A. |
Treatment
of psychoneurotic or psychotic conditions |
| |
B. |
Treatment
of self-correcting conditions such as hoarseness,
developmental articulation errors |
| |
C. |
Language
therapy for young children with natural dysfluency |
| |
D. |
Treatment
of specific developmental delays or speech and
language delays unless specifically covered under
the member contract; e.g., attention deficit
disorders, behavior problems, conceptual handicaps,
mental retardation, psychosocial speech delay |
| |
E. |
Treatment
of stammering and stuttering |
| |
F. |
Treatment
of functional dysphonia |
| |
G. |
Instruction
of other professional personnel in the patient’s
speech therapy program |
| |
H. |
Collaboration
with other professional personnel or with other
community resources |
References
- BlueCross BlueShield Association Medical Policy
Reference Manual, Policy No. 8.03.04
Cross References
Cognitive
Rehabilitation, Regence Medical Policy Manual,
Allied Health, Policy No. 20
Occupational
Therapy, Regence Medical Policy Manual, Utilization
Management Section, No. 4
| Codes |
Number |
Description |
| CPT |
92506 |
Evaluation of speech, language, voice, communication,
and/or auditory processing |
| |
92507 |
Treatment of speech, language, voice, communication,
and/or auditory processing disorder; individual |
| |
92508 |
Treatment of speech, language, voice, communication,
and/or auditory processing; group, two or more
individuals |
| |
92526 |
Treatment of swallowing dysfunction and/or oral
function for feeding |
| HCPCS |
S9128 |
Speech therapy, in the home, per diem |
| |
S9152 |
Speech therapy, re-evaluation |
Utilization Management Table of Contents 
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