Speech Therapy for Autism Disorders Form

1 Speech Therapy for Autism Disorders - Medical Policy Updated Revision Effective: February 1st, 2026 Policy Number: UM623POL Approval Date: Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy) Description People with Autism Spectrum Disorders (ASD) have challenges with communication and social skills. They often find it hard to have conversations and may not notice social cues. Some people with ASD may not verbally communicate at all, and others may not have trouble talking. All people with ASD have some degree of challenge with communication. Speech-language therapy addresses challenges with speaking, language, and communication. High quality speech therapy can help people with autism improve their verbal, nonverbal, and social communication. The overall goal is to help the person communicate in more useful and functional ways. Line of Business Commercial:
Refer to the criteria under the Policy section in this medical policy. Medicaid – BeHealthy:
Refer to the criteria under the Policy section in this medical policy. Medicare:
Refer to the criteria under Policy section in this medical policy. Policy I. Medically Necessary: A. Speech Therapy for individuals with ASD is considered medically necessary when ALL of the following criteria have been met: 11/11/2025

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1. Definitive diagnosis of autism spectrum disorder (ASD) has been made by a neurologist, pediatric neurologist, developmental pediatrician, psychologist, psychiatrist or another licensed physician with a standardized or norm referenced tool such as the Autism Diagnostic Observation Schedule (ADOS). The diagnostician much also have experience in treatment and diagnosis of autism; AND

2. Services are only administered by a qualified speech and language pathologist. A qualified provider is one who is licensed and certified where required and is performing within their scope of practice.

3. Interventional method is consistent with accepted clinical practice standards of professional organizations (e.g., American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Speech-Language Hearing Associations) and should address the specific clinical and functional restrictions (See Policy Guidelines); AND

4. Requests for authorization of initial and ongoing speech therapy treatments must include evidence of initial and periodic re-assessment/re-evaluation (using the same standard clinical tools for comparative purposes) when appropriate, and objective evidence (in functional outcome measures) of progress towards established goals. In addition, there must be documentation confirming the member (and family if applicable) has been compliant with the established treatment plan and has updated long- and short-term goals that are objective, measurable, and attainable within a reasonable and predictable period with further treatment.

   B. Speech therapy is considered MEDICALLY NECESSARY for feeding difficulties determined to be caused by ASD that will benefit from speech therapy. Examples include but are not limited to indications listed under policy guidelines.

   C. For Speech Therapy requests for children with speech and communication delay under 3-years old without a formal ASD diagnosis, refer to Speech Language Pathology (SLP) Services Medical Policy.

   II. Not Medically Necessary:

   A. Services primarily educational in nature.

   B. Services in school settings, provided by school personnel as part of an IEP or ISP (see definitions below).

   C. Services provided in a nonconventional setting such as vocational, educational or recreational settings.

   D. SLP services that do not require the skills of a qualified SLP provider, and/or may be effectively performed by a non-skilled caregiver (e.g., practicing word drills for developmental articulation disorders)

   E. Ongoing services, when progress has plateaued, and further gains are not reasonably anticipated. (Rehabilitative speech therapy is NOT covered when measurable functional improvement based on the goals established by the treating provider is NOT expected or progress has NOT occurred, as documented by the treating provider.)

   F. Personal training or life coaching.

   G. Custodial care – the Member is not showing beneficial response despite multiple trials.

   H. Duplicative services that are part of an Early Intervention Service (EIS) plan of care

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III. Experimental and Investigational:
A. Speech therapy for ASD not meeting above criteria is considered experimental and investigational.

B. Treatment that is investigational or unproven, including, but not limited to facilitated communication, auditory integration therapy (AIT), holding therapy, higashi (daily life therapy).

Policy Guidelines and Definitions

I. Policy Guideline:

A. Any state mandates for ASD diagnosis and treatment take precedence over this medical coverage policy.

B. All requests must meet the medically-necessary-defined criteria as outlined above.

C. Children with ASD may experience many problems with eating, drinking and swallowing that speech and language therapy can help with, including:

1. Recognizing internal feeling surrounding eating, e.g., feeling full or hungry
2. Difficulties with oral motor movements for eating, drinking and swallowing
3. Anxiety and stress surrounding mealtimes
4. Aspiration and dysphagia (unsafe or ineffective swallow)
5. Eating environment
6. Lack of communication during eating and drinking
7. Supporting independence with eating and drinking

8. Helping the child to eat and drink safely D. Speech Therapy:

   Speech and language skills should be evaluated related to the norm and relative to the cognitive ability of the individual. Data should be gathered from the individual or care givers, medical history, school history, previous evaluations for hearing, vision, intelligence, and emotional/behavioral issues. Test results and observations should be noted from contact with the individual. An initial evaluation should include questions that clarify the data above, along with notes on the environment, and whether the individual has an environment adequate to develop speech and language skills consistent with their age and overall potential development.

   Standardized testing should not be the sole tool for the assessment of communication problems; however, objective tests can provide quantitative measures of specific skills and are useful for placement in education programs and in documenting improvement. Specific tests may quantify phonologic ability, vocabulary comprehension, and grammatical usage. A large number of standardized, norm-referenced tests are available for any given age group. Non-standardized and non-norm-referenced tests should not be used.

   Observation and qualitative analysis of the individual’s performance supplement the test results and are essential to diagnosis and to the devising of a treatment plan. In very young children, caregiver report and observation are used. Any test modifications which were necessary or helpful should be noted.

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The final report should include the following information: • The nature of the problem • A description of how the problem affects the individual’s function • The strengths that will enable the individual to compensate for the weakness • Management recommendations • A therapeutic program implementing the recommendations

Specific interventions may include: • Enrollment in individual or group sleep and language therapy • Therapy through a private facility or the public school system • Attendance at a specialized school for children with speech, language, or learning differences • Further assessment of other issues such as oral motor function, general motor function, or behavioral assessment • Assistive technology when applicable • Periodic monitoring without direct therapy

Core features of successful autism programs such as functional analysis of behavior problems, curriculums directed at attention, social interaction, regulation, transition planning, predictability and structure, and self-advocacy are outside the scope of this policy.

II. Definitions:

Autism Spectrum Disorder (ASD): The Diagnostic and Statistical Manual of Mental Disorders, 5th ed., (DSM-5) positions ASD within the broader category of neurodevelopment disorders, which includes deficits in social communication and social interaction across multiple contexts, including deficits in social reciprocity, nonverbal communicative behaviors used for social interaction and skills in developing, maintaining and understanding relationships.
Restrictive repetitive patterns of behavior, interests or activities.

Speech-Language Pathologist (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:

A. Design and implementation of treatment program

B. Establishment of treatment goals, which must be concise, specific, measurable and achievable

C. Establishment of compensatory communication skills (e.g., air injection techniques or word finding strategies)

D. Ongoing and regularly scheduled analysis during implementation phase

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E. Analysis of progress toward goals using objective measurable data

F. The selection and initial training of a device for augmentative or alternative communication systems

G. Evaluation for AAC (Augmentative and Alternative Communication), along with selection and initial training for SGDs (speech-generating devices) and other forms of AAC

H. 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.

Augmentative and Alternative Communication Device (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.

Individualized Education Plan (or Program), also known as an IEP: This is a plan or program developed to ensure that a child with an identified disability who is attending an elementary or secondary educational institution receives specialized instruction and related services. The IEP is developed by a team of individuals from various educational disciplines, the child with a disability, family members, and/or designated advocates. An IEP typically includes the following: • The involvement and progress of the child with a disability in the general curriculum. • All related services for which the child qualifies. • Appropriate educational accommodations necessary for the child to be successful. • The child's present levels of educational performance. • Measurable annual goals and objectives for the child's education.

Individual Service Plan (ISP): Is the core plan of services and supports for a person with a disability, constructed by professionals, paraprofessionals, the focal person (depending on their abilities), and other concerned parties (e.g., parents, advocates). The ISP incorporates relevant comprehensive functional assessment findings, stipulates desired and preferred outcomes, and identifies the full range of services and supports to be provided in order to achieve each outcome. In certain instances, ISPs may be drawn up for individuals with psychiatric conditions, emotional disturbances, or behavior disorders.

Coding Guidance

Code
Description
92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual

CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

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References

https://sltforkids.co.uk/feeding-clinic/problems-we-help/autism-spectrum-disorder-feeding-problems/

https://www.asha.org/public/speech/disorders/autism/

https://www.autismspeaks.org/speech-therapy-autism

https://www.asha.org/practice-portal/clinical-topics/autism/

Paul, R. (2008, October). Interventions to improve communication in autism.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2635569/

Autism Services. (n.d.), Medicaid.com.
https://www.medicaid.gov/medicaid/benefits/autism-services/index.html

AN ACT RELATIVE TO INSURANCE COVERAGE FOR AUTISM. (2010, August 3). Chapter 207.
https://malegislature.gov/Laws/SessionLaws/Acts/2010/Chapter207

Which therapies can help with autism (9-28-2021), WebMD. https://www.webmd.com/brain/autism/benefits-speech-therapy-autism

MassHealth Guidelines for Medical Necessity Determination for Speech and Language Therapy. https://www.mass.gov/guides/masshealth-guidelines-for-medical-necessity-determination-for-speech-and- language-therapy

What is Autism, Autism Navigator (Copyright 2021). https://autismnavigator.com/

Autism Society, The Connection is You. (Copyright 2022).
https://autismsociety.org/

  What is an Individualized Education Plan?

https://www.washington.edu/accesscomputing/what-individualized-education-plan

American Psychological Association. APA Dictionary of Psychology. Individual Service Plan (ISP). https://dictionary.apa.org/individual-service-plan

Wikipedia: Auditory integration training. https://en.wikipedia.org/wiki/Auditory_integration_training

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 4/2017 Initial Policy Date 01/2022 Major criteria updates.

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Date Update 02/2023 No major criteria updates. 1/2024 Line of Business section added. 09/2024 Minor criteria changes. Definitions updated. Removed all references to Pervasive Developmental Disorder (PDD).
8/2025 The following was removed from section I Policy Guidelines: Up to sixteen visits may be authorized initially based on review of the documentation and the member’s plan benefits.
Additional visits will be authorized based on medical necessity.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.