Speech Language Pathology (SLP) Services Form

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Speech Language Pathology (SLP) Services - Medical Policy
Updated Revision Effective: December 1, 2024 Policy Number:

UM339POL

Approval Date: 9/24/2024

Line(s) of Business:

Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Speech language pathology (SLP) services are services that are necessary for the diagnosis and treatment of speech and language disorders that result in communication disabilities and for the diagnosis and treatment of swallowing disorders, even if there is not a communication disability. The services are designed to improve or restore speech and language functioning (communication) following disease, injury or loss of a body part.
Speech pathology also includes evaluation of swallowing.

 Line of Business

Commercial:
Refer to criteria under Policy section in this medical policy.

Medicaid – BeHealthy:

Health New England follows MassHealth Guidelines for Medical Necessity Determination for Speech and Language Therapy. https://www.mass.gov/lists/masshealth-guidelines-for-medical-necessity-determination

o Guidelines for Medical Necessity Determination for Speech and Language Therapy

Medicare:

 For Speech-Language Pathology, Health New England follows Local Coverage Determination (LCD) L33580.

 For Speech-Language Pathology Services for the Treatment of Dysphagia, Health New England follows National Coverage Determination (NCD) 170.3.

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https://www.cms.gov/medicare-coverage-database/search.aspx

Policy

For Commercial:

I. SLP services are considered MEDICALLY NECESSARY when ONE of the following indications is present.

A. Speech delay under age 3 years when medical record documentation confirms ANY of the following:

1. Loss of any language or social skills at any age;
2. No babbling by age 12 months;
3. No gesturing (e.g., pointing, waving bye-bye) by age 12 months;
4. No single words by age 16 months;

5. No two-word spontaneous phrases (not just echolalic) by age 24 months; OR

   B. If the member has speech delay that is associated with a specifically diagnosable disease, injury, or congenital defect (cleft palate, cleft lip, etc.); OR

   C. Speech/language disorders that are the result of a non-chronic disease or acute injury; OR

   D. Bilateral hearing loss caused by sensorineural, mixed conductive and sensorineural, or surgically refractory conductive etiologies in children less than 3 years old.

   E. Voice therapy will be considered for significant voice disorders causing hoarseness when there is a confirmed anatomic abnormality, neurological condition (including Cerebrovascular disease, Parkinson’s disease, Multiple sclerosis), malignancy and/or injury (e.g., edema, vocal nodules or polyps, vocal cord paralysis/paresis, postop vocal cord surgery, vocal tremor, vocal cord bowing; OR

   F. SLP services for functional voice disorders and vocal cord dysfunction will be considered once organic medical conditions (e.g., gastroesophageal reflux disease and asthma) have been excluded and if present are considered adequately treated by the referring provider; OR

   G. Myofunctional disorder or tongue thrust swallow pattern; OR

   H. Swallowing disorders such as dysphagia or feeding disorders that are confirmed to be from a medical condition or a structural abnormality that adversely impacts members ability to safely chew and swallow, or move fluids from the mouth down the throat; OR

   I. Language disorders with inability to comprehend and/or appropriately use language for communication that can affect listening, writing, reading and/or talking; OR

   J. Fluency disorder that includes interruption in the flow of speech, such as stuttering or stammering.

   II. SLP services are considered MEDICALLY NECESSARY for one of the above indications when ALL of the
   following criteria are met:

   A. Services are for the treatment, restoration and improvement of the communication impairment or swallowing disorders; AND

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B. There is a reasonable expectation that the speech therapy will achieve measurable improvement in the member’s condition in a reasonable period of time; AND

C. 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; AND

D. Services are considered to be under currently accepted standards of medical practice to be a specific and effective treatment for the patient’s existing condition.

III. SLP services for Cognitive Rehabilitation are considered MEDICALLY NECESSARY to treat cognitive deficits such as attention, language, memory, reasoning, executive functions, problem solving when ALL of the following criteria are met:

A. The member has been evaluated by either a neurologist, Physical Medicine and Rehabilitation (PM&R) physician (Physiatrist), psychiatrist, neuropsychologist, trauma specialist, concussion clinic and is recommending speech and language therapy, AND

B. The cognitive deficits have been acquired as a result of neurologic impairment due to traumatic brain injury, brain surgery, stroke, or encephalopathy, AND

C. The member is expected to make significant cognitive improvement, e.g., is not in a vegetative or custodial state.

IV. The following services are considered NOT MEDICALLY NECESSARY:

 Accent reduction  Altered auditory feedback devices for stuttering  Attention disorders  Behavioral problems • Bilingual child (speaking two languages) is not considered a developmental speech or delay.
• Chronic cough • Chronic memory disorders • Computer-based learning programs for speech or voice training • Custodial care/non-skilled/repetitive treatment to member who shows no beneficial response despite extended or repeated trials of ST • Dementia • Education services, testing and school performance tests (e.g., SIPT, praxis testing) • Educational interventions • Experimental/investigational or unproven services (e.g., auditory integration therapy, facilitative communication, altered auditory feedback devices) • Group therapy, as this is not 1:1 therapy that is individualized to the member specifically • Hearing loss related to aging process • Instruction by other professional personnel in member’s speech therapy program • Learning disability services (e.g., ADD, ADHD) • Maintenance programs to 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.
• Melodic intonation therapy (MIT) • Mental retardation • Palliative or preventive care

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• Personal training or life coaching • Provision of service in a non-conventional setting (i.e., spas/resorts, vocational or recreational settings) • Psychoneurotic or psychotic conditions • Psychosocial speech delay • Services provided by an out-of-plan provider • Sign language • Social communication group • Speech therapy in a school-based setting • Speech therapy is not considered medically necessary 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 rendered by a SLP assistant or aide • Speech treatments for central auditory processing • Speech/swallowing therapy for feeding aversions without presence of oral and/or pharyngeal dysphagia, G-tube weaning programs or risk of needing a G-tube due to falling below the 10th percentile on the Growth Chart for the National Academy of Pediatrics • The therapy replicates services that are provided concurrently by any other therapy provider without supporting clinical documentation.
• Therapy non-compliance • Treatment to improve or enhance job, school or recreational performance • Treatments that do not require the skills of a qualified provider of speech therapy services, such as treatments which maintain function and are neither diagnostic nor therapeutic or procedures that may be carried out efficiently by the patient, family or caregivers in the home • Vocational or recreationally based treatment

Policy Guidelines and Definitions

Policy Guidelines:

I. There is a separate policy for Speech Therapy for the diagnosis of Autism Spectrum Disorder.

II. Requirements for Initial Determination:

A. The initial evaluation for Speech Therapy services does not require a Prior Authorization (PA).

B. All recommended treatment sessions after initial evaluation require a PA.

C. The care plan should be specific to diagnosis, presenting symptoms and findings at speech therapy evaluation, and must be signed by a qualified speech and language pathologist.

D. All requests must meet the medical necessity criteria as outlined below.

E. Up to a total of 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.

F. For Myofunctional Disorder, number of sessions will be considered on a case-by-case basis. Improvements are typically expected within four visits.

G. If a member is receiving Speech therapy services through the local school system during a typical school year and it has been recommended that services continue during the summer vacation or there is a

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need for additional services, then a documentation from the school-based Speech Language Pathologist to support medical necessity must be submitted for review.

H. If a member is receiving early intervention services (EIS) and it has been recommended that member receive additional services, then documentation from an EIS provider to support medical necessity must be submitted for review.

III. The following information is required to determine the medical necessity for Speech Therapy services:

A. Documented clinical diagnosis of a functional speech disorder as well as unobstructed and patent airway (this is not required if the request is for Cognitive Therapy).

1. The date of onset or exacerbation of the disorder/diagnosis

2. Specific statements of long-term and short-term goals

   B. Quantitative objectives measuring current age-adjusted level of functioning

   C. A reasonable estimate of when the goals will be reached

   D. Specific treatment techniques and/or exercises to be used in treatment

   E. The frequency and duration of treatment

   F. Short- and long-term goals of therapy that must be specific, measurable and objective

   G. A pediatric neurologic or developmental evaluation may be requested.

   H. Evaluation supporting medical necessity by the referring provider is required before authorization of SLP services for treatment of any voice disorder in pediatric and adult patients.

   I. If a child is not receiving ST services at school, HNE may approve if medically necessary. (Notation will be made in the letter to the member that member may seek services through school system).

   IV. The following information is required for Subsequent or Ongoing Treatment Determination:

   A. Regular assessment and reevaluation

   B. Documented progression toward both long- and short-term goals using measurable outcomes

   C. Documentation of home (self) management program

   D. Updated treatment plan of interventions, goals and timeframes

3. If a member is receiving Speech therapy services through the local school system during a typical school year and it has been recommended that services continue during the summer vacation or there is a need for additional services, then a documentation from the school-based Speech Language Pathologist to support medical necessity must be submitted for review.

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2. If a member is receiving early intervention services (EIS) and it has been recommended that member receive additional services, then documentation from an EIS provider to support medical necessity must be submitted for review.

3. Functional progress may be demonstrated in the documentation by improving communication skills which may include:

   • improving ability to express coherent thoughts effectively • improving direction-following and understanding/asking of questions • improving expressive and receptive vocabulary • improving linguistic memory of information read or heard • improving oral and written grammar and syntax • improving pragmatic language skills, including verbal and nonverbal language • improving preliteracy or literacy skills, improving receptive and expressive language for both oral and written language • increasing expressive utterance length and complexity

   Definitions:

   Rehabilitative therapy is aimed at regaining or improving skills and functioning of daily living skills. This therapy is due to impairment as a result of illness, injury or disability.

   Habilitative therapy helps an individual keep, learn or improve skills for functioning of daily living skills (i.e., not speaking at the expected age).

   Cognitive rehabilitation offers retraining in the ability to think, use judgment, and make decisions.

   Melodic intonation therapy (MIT) is a technique using rhythmic and melodic components to assist patients with aphasia in speech recovery.

   Developmental delay is a condition in which a child is not achieving or developing according to expected milestones.

   Functional impairment is a direct and measurable reduction in physical performance.

   Dysphagia is a condition where swallowing takes more time and effort to move liquids or food from mouth to stomach.

   Dysphonia is an impairment of the speaking or singing voice. This is characterized by alteration in pitch, loudness, vocal quality or vocal effort. This impacts communication or reduces voice-related quality of life.

   Dysfluency is frequent blocking of speech or involuntary disruption.

   Stammering occurs when sounds or syllables are repeated, or sounds made longer or when the word gets stuck and does not come out at all. Stammering can be developmental or acquired or late-onset.

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Stuttering is a communication disorder that presents with excessive involuntary disruptions. The disruptions are in the smooth and rhythmic flow of speech. This consists of repetitions, prolongation of a sound or syllable when they are accompanied by emotions and behaviors of avoidance and struggle.

Dysphasia is an impairment of the power of expression by speech, writing or signs. Can also impair the power of comprehension of spoken or written language. Other more serious forms of dysphasia are aphasia.

Global aphasia is severe and extensive damage to the language areas of the brain. Loss of almost all language function, inclusive of comprehension and expression. Loss of ability to understand or to speak. Reading and writing are also lost.

Broca’s aphasia or Expressive aphasia entails intact comprehension but difficulty speaking fluently.

Wernicke’s aphasia or Receptive aphasia entails inability to grasp the meaning of spoken words and sentences, but ability to express speech is not significantly impaired.

Apraxia of speech is characterized by slowed speech, speech sound distortions including sound substitutions and inconsistent errors. Not due to problems in strength, speed or coordination of articulatory musculature.

Functional voice disorders (FVD) are caused by insufficient or improper use of the phonation apparatus without either anatomical or neurological abnormalities. The most common FVDs include vocal fatigue, muscle tension dysphonia, diplophonia, and ventricular phonation.

Vocal cord dysfunction (VCD) or paradoxical vocal fold movement (PVFM) occurs when the vocal cords (voice box) do not open correctly. This unintended closure of the vocal cords (folds) causes the gasping sound sometimes heard when exercising heavily. VCD can have this inhalatory stridor (gasping) even when resting.

Coding Guidance

Code
Description
Requires PA CPT Codes

70371 Complex dynamic pharyngeal and speech evaluation by cine or video recording. NO 92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual.

YES 92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals. YES 92521 Evaluation of speech fluency (e.g., stuttering, cluttering). NO (PA required for SNF setting)

92522 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria). NO (PA required for SNF setting) 92523 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language). NO (PA required for SNF setting)

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Code
Description
Requires PA 92524 Behavioral and qualitative analysis of voice and resonance NO (PA required for SNF setting) 92526 Treatment of swallowing dysfunction and/or oral function for feeding
YES 96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston diagnostic aphasia examination) with interpretation and report, per hour
NO 92610 Evaluation of oral and pharyngeal swallowing function. NO 92626 Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); first hour. NO 92627 Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); each additional 15 minutes (List separately in addition to code for primary procedure).
NO 92609 Therapeutic services for the use of speech-generating device, including programming modification. YES 92630 Auditory rehabilitation; prelingual hearing loss. YES 92633 Auditory rehabilitation; postlingual hearing loss. YES HCPCS Codes

V5362 Speech evaluation
NO (PA required for SNF setting) V5363 Language screening
NO (PA required for SNF setting) S9152 Speech therapy, re-evaluation
NO (PA required for SNF setting) CPT® Copyright 2024 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.

References

The 191st General Court of the Commonwealth of Massachusetts. https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter175/Section47X

Frequently Asked Questions About Voice Therapy.

https://www.asha.org/SLP/clinical/Frequently-Asked-Questions-About-Voice-Therapy

American Speech Language-Hearing Association

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Hayes, K., RN. (2020, January 13). Types of Speech Therapy.

https://www.verywellhealth.com/types-of-speech-therapy-1192153

Who Are Speech-Language Pathologists, and What Do They Do?

https://www.asha.org/public/Who-Are-Speech-Language-Pathologists

American Speech-Language-Hearing Association

Gierut, J. A., Morrisette, M. L., & Ziemer, S. M. (2009). Nonwords and Generalization in Children With Phonological Disorders.

https://pubs.asha.org/doi/10.1044/1058-0360(2009/09-0020)

American Journal of Speech-Language Pathology

MassHealth Guidelines for Medical Necessity Determination for Speech and Language Therapy (3/30/2017), https://www.mass.gov/guides/masshealth-guidelines-for-medical-necessity-determination-for-speech- andlanguage-therapy

Speech-Language Pathology Medical Review Guidelines, American Speech-Language-Hearing-Association

https://www.asha.org/Practice/reimbursement/SLP-medical-review-guidelines/

Year 2019 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs https://digitalcommons.usu.edu/cgi/viewcontent.cgi?article=1104&context=jehdi

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 10/2008 Initial Policy Date 05/2023 Moved to new template with minor changes to existing criteria. Added criteria for children under 3.
09/2023 Added Criteria I D to Policy Section. 10/2023 Clarified IV D 1 under policy guidelines and definitions. Added links to Medicare and MassHealth.
1/1/2024 Added Line of Business section.

09/2024 Reviewed with no changes.

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

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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.