Speech Therapy

POLICY NUMBER

L.8.03.402

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 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 a disabling health condition caused by disease, trauma, congenital anomalies or prior therapeutic intervention in accordance with an individualized specific treatment plan.

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.

Effective 01/01/2021, speech therapy services are considered medically necessary for the treatment of Pediatric or Developmental Disorders or Delays that are documented as resulting in speech less than the 20th percentile (more than 1 standard deviation less than the norm) or a 15% age delay on standardized testing. Scaled score norms are usually 10 with a standard deviation of +/- 3, or Standard Scores of 100 with a standard deviation of 15. These Disorders or Delays include the following:

• Childhood stuttering and stammering severe or present for more than 6 months, under nine years of age

• Childhood speech apraxia that is not part of a global developmental delay; or

• Disarticulation, articulation disorder

• Dysarthria

• Expressive language disorder or delay

• Phonological disorder

• Receptive language disorder or delay

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:

• Developmental problems, including, but not limited to, developmental delay with results above the 20th percentile or less than a 15% age delay on standardized testing;

• Learning disabilities with no underlying disabling health condition;

• Attention disorders;

• Psychosocial speech delay;

• Behavioral problems;

• Conceptual handicap;

• Mental retardation;

• Stammering, stuttering that does not meet medical necessity criteria above.

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:

• Treat the needs of a patient who suffers from communication impairment or swallowing disorder, due to a disabling health condition caused by 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.

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.

POLICY EXCEPTIONS

State Health Plan (State and School Employees): Speech therapy services for delayed language development are limited to a lifetime maximum of 15 visits. Speech therapy is not covered for maintenance speech, articulation disorders, learning disabilities, attention disorders, psychosocial speech delay, behavioral problems, conceptual handicap, mental retardation, stammering or stuttering.

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

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 arenotcovered.

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

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

9/1994: 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 9-30-2007. 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.

04/15/2015: Updated policy guidelines to add medically necessary and investigational definitions. CPT code 92524 moved from not medically necessary to covered in the Code Reference section. Removed deleted CPT code 92506 and ICD-9 diagnosis code 784.5 from the covered codes table in the Code Reference section.

09/01/2015: Code Reference section updated for ICD-10. Removed ICD-9 procedure codes 93.72, 93.73, 93.74, and 93.75.

05/27/2016: Policy number L.8.03.402 added.

05/18/2018: Medical policy link updated in policy section.

12/23/2020: Policy statement updated to add coverage criteria for treatment of Pediatric or Developmental Disorders or Delays effective 01/01/2021. Policy Exceptions added for State Health Plan Participants to state that Speech therapy services for delayed language development are limited to a lifetime maximum of 15 visits. For State Health Plan Participants, speech therapy is not covered for maintenance speech, articulation disorders, learning disabilities, attention disorders, psychosocial speech delay, behavioral problems, conceptual handicap, mental retardation, stammering or stuttering. Code Reference section updated to move CPT code 92521 to the Covered Codes table. Also added ICD-10 diagnosis codes F80.0 - F80.9. Sources section updated.

07/20/2021: Policy statement criteria revised to state that speech therapy services are not medically necessary for the following conditions: learning disabilities with no underlying disabling health condition.

06/30/2023: Policy reviewed; no changes.

06/24/2024: Policy reviewed; no changes.

10/01/2025: Code Reference section updated to add new ICD-10 diagnosis code G31.87.

SOURCE(S)

1. 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

2. Blue Cross Blue Shield Association policy # 8.03.04

3. Capital Blue Cross Speech Therapy (Outpatient) Medical Policy

4. Hayes Medical Technology Directory

CODE REFERENCE

This 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.

Covered Codes 

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.