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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.
POLICYSpeech therapy services are eligible for coverage provided they meet the criteria stated in this policy. These 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 medically necessary for the treatment of autism spectrum disorder as outlined in the Treatment of Autism Spectrum Disorder (ASD) medical policy.
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.
Speech therapy services are not medically necessary for the following conditions:
A speech therapy session is defined as up to one hour of speech therapy (treatment and/or evaluation) on any given day.
Speech therapy sessions must meet all of the following criteria:
Certain types of treatment do not generally require the skills of a qualified provider of speech therapy services, such as treatments which maintain function by using routine, repetitions, and reinforced procedures that are neither diagnostic nor therapeutic (for example; 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.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
Speech therapy as limited in the Schedule of Benefits and this section is covered up to the Benefit maximum or when maintenance level of therapy is attained (whichever the Member reaches first). A maintenance program consists of activities that preserve the Member's present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Benefits for a maintenance program are not covered.
Inpatient benefits are considered not medically necessary if the hospital admission is solely for the purpose of receiving speech therapy.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY9/1994: Issued
11/1997: Prior authorization required; expanded description of non-covered services
2/14/2002: Investigational definition added
2/27/2002: Prior Authorization and Managed Care Requirements deleted
3/6/2002: Treatment plan submission to BCBSMS requirements before initiation of treatment deleted
5/7/2002: Type of Service and Place of Service deleted
6/23/2004: Policy reviewed, Sources updated
11/19/2004: Code Reference section updated, CPT 92506 added, CPT code 92598 typo should be 92508, ICD-9 procedure code range 93.72-93.75 listed separately, ICD-9 diagnosis code V57.3 added, HCPCS S9128 added
3/21/2006: Coding updated. CPT4 2006 revisions added to policy
4/11/2006: Policy reviewed, no changes
9/18/2006: Coding updated. ICD9 2006 revisions added to policy.
6/14/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
9/20/2007: Code Reference section updated. ICD-9 2007 revisions added to policy
9/29/2009: Code Reference section updated. New ICD-9 diagnosis codes 784.42, 784.43, 784.44, 784.51 and 784.59 added to covered table. Deleted statement added to ICD-9 code 784.5. ICD-9 diagnosis code 784.9 deleted from covered due to code was deleted as of 9-30-2006. ICD-9 diagnosis code 787.2 deleted from covered table due to code was deleted as of 90-30-2007. Description revised for ICD-9 code 784.49. Code description revised for ICD-9 diagnosis code V57.3.
06/03/2010: Policy description and statement unchanged. Updated the Code Reference section to add the following statement to ICD-9 code 784.59: "Use to report non-developmental articulation disorder."
03/08/2013: Policy reviewed; no changes.
02/18/2014: Added the following new 2014 CPT codes to the Covered Codes table: 92522 and 92523. Created a Not Medically Necessary Codes table and added the following new 2014 CPT codes: 92521 and 92524.
03/16/2015: Policy statement updated to state that speech therapy services are considered medically necessary for the treatment of autism spectrum disorder as outlined in the Treatment of Autism Spectrum Disorder (ASD) medical policy. Added link to the Treatment of Autism Spectrum Disorder (ASD) medical policy.
SOURCE(S)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 Headings: Speech Therapy. Research was limited to English-language journals on humans
Hayes Medical Technology Directory
Blue Cross Blue Shield Association policy # 8.03.04
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
Not Medically Necessary Codes