Prior authorization request form Form

Speech-Language Pathology — Interventional Services for Autism Spectrum Disorders Last Review Date: March 14, 2025 Number: MG.MM.ME.45bC9

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Autism spectrum disorders (ASDs) Group of biologically based neurodevelopmental disorders characterized by impairments in three major domains: Socialization, communication and behavior. The Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) positions ASDs within the broader category of pervasive developmental disorders (PDDs); which includes autistic disorder, Asperger syndrome, childhood disintegrative disorder, Rett syndrome and pervasive developmental disorder—not otherwise specified PDD—NOS). The ASDs feature varying degrees by difficulties in social interaction, verbal and nonverbal communication (e.g., gestures, eye contact, facial expressions, etc.), and repetitive behaviors. While variability exists regarding communication skills, the majority of children with ASDs have difficulty using language effectively. Problems include ascertaining the meaning and rhythm of words and sentences, and an inability to understand body language and nuances of vocal tones. Augmentative and alternative communication (AAC) Any combination of devices, aids, techniques, symbols, and/or strategies to represent and/or augment spoken and/or written language or to provide an alternative mode of communication; speech-generating devices (SGDs) are included in this category.

Speech-language pathologists (SLPs) Provide services for the diagnosis and treatment of speech and language disorders resulting in communication disabilities. The goal of interventional services is to improve all aspects of communication — comprehension, expression, sound production and the social use of language (i.e., pragmatics). SLPs provide services as members of collaborative teams that include the individual, family/caregivers, and other relevant persons (e.g., educators, medical personnel) and implement a multimodal approach to enhance effective communication that is culturally and linguistically appropriate. Services include:

1. Design and implementation of treatment program.
2. Establishment of treatment goals, which must be concise, specific, measurable and achievable.
3. Establishment of compensatory communication skills (e.g., air injection techniques or word finding strategies).
4. On-going and regularly scheduled analysis during implementation phase.
5. Analysis of progress toward goals using objective measurable data.
6. The selection and initial training of a device for augmentative or alternative communication systems.
7. Evaluation for ACC, along with selection and initial training for SGDs and other forms of ACC.

8. Patient and family training to augment restorative treatment or to establish a maintenance program. Education of staff and family must begin at the time of evaluation.

   Guidelines (Delineation of clinical indications may be found in the Appendix — Select Interventions, Applications and Outcomes from the American Speech-Language-Hearing Association Preferred Practice Patterns for the Profession of Speech-Language Pathology)

9. Speech therapy; all: a. Reasonable expectation of benefit in function, activity and participation in a reasonable and generally predictable period of time.
   b. Interventional method is consistent with accepted clinical practice standards from national professional organizations (e.g., American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Speech-Language Hearing Association, etc.).
   c. Amount, frequency and duration of service is reasonable, as consistent with accepted clinical practice standards.
10. Augmentative and Alternative Communication; either:
    a. AAC system: i. Ability to communicate is impaired to the extent that an AAC system is needed to support communication activity and participation. Member was evaluated to determine that he/she meets the visual, motor, sensory, reading/literacy, writing, linguistic and cognitive requirements to successfully operate the recommended device. ii. Recommended device was trialed along with at least 2 other appropriate and reasonable devices with a feature-by-feature comparison (feature matching) of the 3 (or more) devices and an explanation for why the selected device is the superior choice.
    b. SGD:
    i. Permanent and severe expressive speech impairment such as dysarthria, anarthria, aphasia,
    aphonia, childhood apraxia of speech, or nonverbal with an undetermined cause. ii. Speaking needs cannot be met using natural communication methods (i.e., speech, sign language). iii. Other forms of treatment have failed, are contraindicated, or are otherwise not appropriate. iv. An SGD is available in the individual’s primary language and is being requested for the sole purpose of speech generation. v. Reasonable expectation of benefit from use of the device. Documentation Progress notes should address the following:
11. Type and severity of communication disorder.

2. Objective test data (or if formal testing is not possible, a thorough description of informal test results and/or skills).
3. The nature of the service provided.
4. Ability to learn and retain instruction.
5. Impact on activity and participation across educational, vocational and social settings with essential outcomes
   communicated on the following: a. Formation of relationships. b. Functional effectiveness. c. Active participation in everyday life. Limitations/Exclusions
6. EmblemHealth provides coverage for computer software and/or applications that enable a non dedicated device to function as a SGD; however, SGDs and other devices, which are not medical in nature, are not considered medically necessary — these include general/multi-purpose electronic consumer devices (e.g., personal digital assistants [PDAs], computers, tablet devices such as iPads, smart phones, electronic mail devices, pagers, etc.).
7. Services must be provided by a qualified SLP defined as meeting either of the following requirements:
   a. The education and experience requirements for a Certificate of Clinical Competence in Speech-Language Pathology granted by the American Speech-Language-Hearing Association. b. The educational requirements for the Certificate of Clinical Competence in Speech-Language Pathology granted by the American Speech-Language-Hearing Association, and is in the process of accumulating the supervised experience required for certification.
8. Services are not considered medically necessary once the stated objectives/predicted outcomes have been achieved: a. No expectation of further benefit (no significant increase in standard score or failure to achieve goals).

9. Members receiving school-based speech therapy services from a qualified SLP are not eligible for coverage of duplicate services provided by another SLP. Revision History 9/11/15 — added to AAC device criteria the prerequisite of feature-by-feature comparison trials with devices other than that which was recommended. Applicable ICD-10 Diagnosis Codes F84.0 Autistic disorder F84.2 Rett's syndrome F84.3 Other childhood disintegrative disorder F84.5 Asperger's syndrome F84.8 Other pervasive developmental disorders F84.9 Pervasive developmental disorder, unspecified G31.81 Alpers disease

   Applicable Procedure Codes 92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual 92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals 92597 Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech 92521 Evaluation of speech fluency (eg, stuttering, cluttering)

92522 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria) 92523 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)
92524 Behavioral and qualitative analysis of voice and resonance E2500 Speech generating device, digitized speech, using prerecorded messages, less than or equal to 8 minutes recording time E2502 Speech generating device, digitized speech, using prerecorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time E2504 Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time E2506 Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time E2508 Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device E2510 Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access E2511 Speech generating software program, for personal computer or personal digital assistant E2512 Accessory for speech generating device, mounting system E2513 Accessory for speech generating device, electromyographic sensor (eff. 10/1/2024) E2599 Accessory for speech generating device, not otherwise classified S9152 Speech therapy, re-evaluation S9128 Speech therapy, in the home, per diem G0161 Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes K0739

Repair or non routine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes

References
American Academy of Child and Adolescent Psychiatry. Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults With Autism and Other Pervasive Developmental Disorders. 2013. https://www.jaacap.org/article/S0890-8567(13)00819- 8/fulltext. Accessed March 21, 2025.
American Academy of Pediatrics. Management of Children With Autism Spectrum Disorders. 2007. http://pediatrics.aappublications.org/content/120/5/1162.full.pdf+html. Accessed March 21, 2025.
American Speech-Language-Hearing Association. Evidence-Based Practice in Communication Disorders .2005.
https://www.asha.org/policy/ps2005-00221/. Accessed March 21, 2025.
American Speech-Language-Hearing Association. Augmentative and Alternative Communication (AAC). 2020. http://www.asha.org/SIG/12/default/. Accessed March 21, 2025.
Folia Phoniatr Logop. 2017;69(1-2):78-83. doi: 10.1159/000479586. Epub 2017 Dec 15. Stimulation of Executive Functions as Part of the Language Intervention Process in Children with Autism Spectrum Disorder. Sun IYI1, Varanda CA1,2, Fernandes FD1. Neuropsychiatr Dis Treat. 2016 Sep 1;12:2255-63. doi: 10.2147/NDT.S108899. eCollection 2016. Children who screen positive for autism at 2.5 years and receive early intervention: a prospective naturalistic 2-year outcome study. Spjut Jansson B1, Miniscalco C2, Westerlund J3, Kantzer AK4, Fernell E5, Gillberg C5. National Government Services. Local Coverage Article: Billing and Coding: SPEECH-Language Pathology (A52866). January 2025. https://www.cms.gov/medicare-coverage- database/view/article.aspx?articleid=52866&ver=34&keyword=speech&keywordType=starts&areaId=all&docType=NCA%2CCAL%2CNCD% 2CMEDCAC%2CTA%2CMCD%2C6%2C3%2C5%2C1%2CF%2CP&contractOption=all&sortBy=relevance&bc=AAAAAAQAAAAA&KeyWordLook Up=Doc&KeyWordSearchType=Exact. Accessed March 21, 2025.
U.S. Department of health & human services ∙ national institutes of health ∙ national institute on deafness and other communication disorders. NIDCD Fact Sheet Communication Problems in Children with Autism. https://www.nidcd.nih.gov/health/autism-spectrum- disorder-communication-problems-children. Accessed March 21, 2025.

Specialty matched clinical peer review.

APPENDIX Select Interventions Applications and Outcomes from the American Speech-Language-Hearing Association Preferred Practice Patterns for the Profession of Speech-Language Pathology

Interventional Focus Expected Outcomes (Typically result in improved abilities, functioning, participation and contextual facilitators; this text is not repeated per row) Counseling Information and support for the development of problem-solving strategies N/A Communication Infants and toddlers

1. Preverbal communication (e.g., helping the family/caregiver be sensitive to the infant's or toddler's physical states and needs, gestural and other means of conveying them, and helping them learn to foster the development of preverbal expressions of communicative intentions and turn- taking).
2. Feeding and swallowing skills.
3. Early receptive language skills (e.g., understanding words, sentences, and communicative intentions with and without nonverbal supports).
4. Early expressive language skills (e.g., babbling, producing early words and sentences; expressing a variety of communicative functions verbally and nonverbally).
5. Social interaction, play, and emergent literacy skills (e.g., engaging in joint action routines; interacting with family/caregivers using toys, baby books and other age-appropriate literacy materials). May function as prevention for communication problems (e.g., delayed language because of preterm status). Preschool Speech-Language and Communication
6. Receptive language skills (e.g., attention and listening skills; vocabulary development; following directions; understanding sentences and stories; responding to communicative intent of peers and adult partners).
7. Expressive language skills (e.g., using age-appropriate phonology and articulation skills; using a variety of words; formulating simple and complex sentences; expressing a variety of communicative functions; engaging with peers).
8. Play, social interaction, and emergent literacy skills (e.g., using toys, props, and literacy materials in dramatic play; interacting appropriately with peers and adult partners; interacting with Reduction of risks for literacy learning difficulties.

Interventional Focus Expected Outcomes (Typically result in improved abilities, functioning, participation and contextual facilitators; this text is not repeated per row) books and demonstrating emergent writing skills).

4. Oral narrative skills (from sequences to simple stories).
5. ACC and/or other assistive technology, as appropriate. Speech Sound
6. Selection of intervention targets based on the results of an assessment of the client/patient's articulation and phonology.
7. Improvement of speech sound discrimination and production.
8. General facilitation of newly acquired articulation and/or phonological abilities to a variety of speaking, listening, and literacy-learning contexts.

9. Increased phonological awareness of sounds and sound sequences in words and relating them to print orthography (when age-appropriate).

   Spoken and Written Language Intervention—School-Age Children and Adolescents

10. Knowledge and use of language for listening, speaking, reading, writing, and thinking, including — a. phonology and print symbols (orthography) for recognizing and producing intelligible spoken and written words; b. syntactic structures and semantic relationships for understanding and formulating complex spoken and written sentences; c. discourse structures for comprehending and organizing spoken and written texts; d. pragmatic conventions (verbal and nonverbal) for communicating appropriately in varied situations; e. metacognitive and self- regulatory strategies for handling complex language, literacy, and academic demands.
11. Improved spoken and written language abilities.
12. Improved social, academic, and/or vocational functioning and participation.
13. Improved contextual facilitators. Spoken and Written Language Intervention — adults
14. Knowledge and use of language for listening, speaking, reading, writing, and thinking, including — f. phonology and print symbols (orthography) for recognizing and producing
15. Reduced deficits and contextual barriers.
16. Improved spoken and written language abilities and contextual facilitators.
17. Measurably enhanced functioning and participation.

Interventional Focus Expected Outcomes (Typically result in improved abilities, functioning, participation and contextual facilitators; this text is not repeated per row) g. intelligible spoken and written words; h. syntactic structures and semantic relationships for understanding and i. formulating complex spoken and written sentences; j. discourse structures for comprehending and organizing spoken and written pragmatic rules for communicating appropriately in varied situations; k. metacognitive and self- regulatory strategies for handling complex language and literacy demands.

2. Spoken and written language for social, educational, and vocational activities, with an emphasis on participation in specific activities identified as problematic for the individual.
3. Contextual factors that influence the individual's relative success or difficulty in those activities.
4. Compensatory communication techniques and strategies including the use of augmentative and alternative communication or other assistive technology.
5. Training of others in the individual's environment to use communication strategies, cuing techniques, and/or assistive technology to support increased comprehension of spoken and written language and to facilitate increased spoken and written output.
6. Development of plans, including referral, for problems co-occurring with spoken and written language disorders, such as hearing or visual difficulties, speech or voice disorders, and motional disturbance. Severe Communication Impairment
7. Assist the individual to experience the positive value of human communication and interaction.
8. Work with others to understand the message value of maladaptive behaviors and replacing them with more socially acceptable means of communication and self-regulation (e.g., nonverbal, gestural, AAC-
9. Improved forms of socially appropriate communication, incorporating combinations of nonverbal, gestural, spoken, written, augmentative and alternative communication (AAC) modes.
10. Corresponding reductions in challenging behaviors; improved social, academic, and/or

Interventional Focus Expected Outcomes (Typically result in improved abilities, functioning, participation and contextual facilitators; this text is not repeated per row) supported, spoken and written language).

9. Modify contextual factors that influence the individual's relative success or difficulty in key activities.
10. Identify life goals of the individual and family/caregivers related to social, educational, and vocational activities and participation. vocational functioning and participation. Augmentative and Alternative Communication (AAC)
11. Identify and educate the
    patient/client, family/caregivers, and relevant others in the AAC system's operation.
12. Plan for optimum patient/client use, including education in maintaining the AAC system and programming updates and modifications for conversational, academic, and other uses.
13. Use the AAC system while targeting any other speech-language (spoken or written) and communication goals and objectives appropriate to activity/participation needs and the individual's age and abilities (e.g., vocabulary, sentence comprehension and production, reading and writing, conversational turn-taking and judging listener needs, natural speech and voicing).
14. Use the AAC system for multiple functions in multiple contexts (e.g., educational, vocational, social).
15. Helps patients/clients, their communication with partners, teachers, parents/spouses/caregivers to understand, use, maintain, and update personalized
16. AAC systems and other assistive technology.
17. Promotes language learning and function, optimizes communication abilities, and increases activity/participation.
    Fluency
18. Provide information and guidance to patients/clients, families, and other significant persons about the nature of stuttering, normal fluency and disfluency, and the course of intervention and prognosis for recovery.
19. Complexities of a fluency disorder, including possible reactions.
20. Defensive behaviors, coping strategies of the person who has the fluency disorder, and the reactions of significant others in the listening environment.
21. Reduction of the frequency with which stuttering behaviors occur without
22. increasing the use of other behaviors that are not a part of normal speech production.
23. Reduction of the severity, duration, and abnormality of stuttering-like Improved fluency abilities.

Interventional Focus Expected Outcomes (Typically result in improved abilities, functioning, participation and contextual facilitators; this text is not repeated per row) disfluencies in multiple communication contexts.

7. Reduction of the use of defensive behaviors (e.g., avoidance behaviors).
8. Removal or reduction of barriers serving to create, exacerbate, or maintain stuttering behaviors (e.g., parental reactions, listener reactions, client perceptions).
9. Assisting the person who stutters to communicate in educational, vocational, and social situations in ways that optimize activity/participation.
10. Reduction of attitudes, beliefs, and thought processes that interfere with fluent speech production or that hinder activity/participation.
11. Reduction of emotional reactions to specific stimuli when they have a negative impact on stuttering-like disfluencies, attempts to modify stuttering behavior, and/or activity/participation. Cognitive-Communication and/or Language Impairments Associated With Auditory Processing Disorders (APD)
12. Formulation of an intervention plan based on concerns, symptoms, history,
13. auditory processing test results, and participation in activities that have been identified as problematic.
14. Enhancement of cognitive- communication and language resources for processing spoken and written language at the phoneme, word, sentence, and discourse level, and using these structures in functional contexts.
15. Recommendations for optimizing the listening environment, removing barriers and enhancing facilitators of activity/participation.
16. Improvement of auditory processing ability through auditory training and stimulation, language comprehension and production strategies, and/or attention to metalinguistic and metacognitive skills and strategies.
17. Generalization of skills and strategies through supported practice in the natural environment.
18. Counseling for individuals, family/caregivers, educators, and other relevant persons.
19. Auditory processing and listening abilities
20. Language and cognitive- communication abilities