Description

Speech therapy involves the diagnosis, study and treatment of verbal communication and language in people of all ages to enable them to communicate to the best of their ability. Speech therapy is also used to evaluate and treat dysphagia (swallowing disorders).

Speech therapy services are provided by, or under the direction of, licensed speech- language pathologists. Speech-language pathologists (also referred to as speech therapists) assess, diagnose, help prevent and treat disorders related to fluency (flow of speech), language, speech, swallowing and voice.

Speech therapy services may be considered rehabilitative OR habilitative:

Rehabilitative services

refers to speech therapy services that help an individual regain or improve skills and functioning for daily living that have been lost or impaired because an individual was sick, injured or disabled.

Habilitative services

refers to speech therapy services that help an individual keep, learn or improve skills and functioning for daily living. An example would include therapy for a child who isn't talking at the expected age.

Melodic intonation therapy (MIT)

is a treatment technique that uses melodic and rhythmic components to purportedly assist in speech recovery for individuals with aphasia (e.g., loss of the ability to produce or understand language). (Refer to Coverage Limitations section)

For information regarding fluency enhancing devices, speech generating devices and voice prostheses, please refer to Speech Generating Devices, Voice Prostheses Medical Coverage Policy.

For information regarding voice therapy as part of gender affirmation surgery, please refer to Gender Affirmation Surgery Medical Coverage Policy.

Coverage Determination

Rehabilitative Speech Therapy

Any state mandates for rehabilitative speech therapy take precedence over this clinical policy.

Refer to specific certificate language regarding rehabilitative speech therapy. Most certificates limit the duration or number of visits.

Any services for rehabilitative speech therapy that are considered primarily educational or training in nature are generally NOT covered under most Humana benefit Plans.

General Criteria for Rehabilitative Speech Therapy

Humana members may be eligible under the Plan for rehabilitative speech therapy when ALL of the following criteria are met:

• Participating physician or other licensed healthcare professional acting within their state-specific licensure has determined that the condition can improve significantly within 3 months of the date that therapy begins; AND
• Rehabilitative speech therapy may be performed for conditions related to a defect, developmental delay*, functional impairment** or pain as evidenced by supporting documentation recorded in medical records submitted for review; AND
• Rehabilitative speech therapy services must be performed by a duly licensed and certified, if applicable, provider.

All services provided must be within the applicable scope of practice for the provider in their licensed jurisdiction where the services are provided; AND

• Rehabilitative speech therapy services provided must be of the complexity and nature to require that they are performed by a licensed speech-language pathologist or provided under their direct supervision by a licensed ancillary person as permitted under state laws; AND
• Rehabilitative speech therapy services must be provided in accordance with an ongoing, written, individualized plan of care that is reviewed with and approved by the treating physician or other licensed healthcare professional acting within their state specific licensure. The plan of care should be of sufficient detail and include appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment. This information should include at least the following:

1. Speech therapy evaluation; AND
2. Frequency and duration of the treatments provided must be reasonable and customary under the generally accepted standards of practice for speech therapy; AND
3. Reasonable estimate as to the time when these goals will be achieved; AND
4. Short- and long-term goals that are specific, quantifiable (measurable) and objective; AND
5. Specific speech therapy techniques, treatments or exercises to be used;

Speech Therapy Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0324-020
Page: 4 of 16

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Signatures, license numbers and professional license designations of the treating speech-language pathologist and treating physician or other licensed healthcare professional acting within their state specific licensure must be affixed to the evaluation and/or ongoing treatment reports. The individual must be reevaluated at least monthly, and the results of these evaluations recorded in a standard format. The progress towards achieving the stated goals must be assessed and if needed, changes made in the treatment program as a result of the evaluations; AND

Rehabilitative speech therapy may be appropriate for acute episodes or significant exacerbations of chronic/longstanding/previously known medical or surgical conditions

Developmental delay describes the condition in which a child is not developing and/or achieving skills according to the expected time frame.
Functional impairment describes a direct and measurable reduction in physical performance of an organ or body part.

Rehabilitative speech, language and communication evaluation may be appropriate for the following conditions including, but not limited to:

• Autism spectrum disorders; OR
• Behavioral disabilities; OR
• Intellectual disability/intellectual development disorder (impairments of general mental abilities that impact adaptive functioning from conceptual, social and practical domains); OR
• Learning disabilities

Speech Therapy Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0324-020
Page: 5 of 16

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Rehabilitative speech therapy may be medically necessary in the treatment of communication disabilities and/or dysphagia (swallowing disorders) that are the result of the following conditions including, but not limited to:

• Cerebral anoxia/hypoxia including neonatal asphyxia; OR
• Cerebrovascular accident (CVA); OR
• Congenital anomaly; OR
• Head injury; OR
• Neuromuscular disorders (such as Parkinson’s disease); OR
• Postoperative conditions; OR
• Surgery of the larynx or vocal cords

Note: The criteria for rehabilitative speech therapy for the treatment of dysphagia are not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage Limitations

Rehabilitative Speech Therapy

Humana members may NOT be eligible under the Plan for rehabilitative speech therapy for any indications other than those listed above including, but not limited to, the following:

• Duplicate therapy – receiving multiple therapies (physical, occupational and/or speech therapy) for the same clinical condition. When multiple therapies are used, each must have separate written treatment plans and must provide significantly different treatments and not be seen as generally duplicating each other; OR
• Educational purposes, as such services are generally excluded in the certificate (Please consult the member’s individual certificate regarding Plan coverage); OR
• Functional dysphonia (absence of an anatomic laryngeal abnormality); OR
• Group therapy (as this is not one-on-one and individualized); OR
• Hearing loss related to the aging process; OR
• Maintenance care consists of activities that generally are intended to preserve the present level of function and/or prevent regression of that level of function including, but may not be limited to, the following:

1. Maintenance begins when the therapeutic goals of the treatment program are achieved or when no further significant progress is made or reasonably seen as occurring; AND
2. Individual has achieved generally accepted normal levels of function and/or muscle strength and has reached a plateau (generally a period of 4 weeks or less, depending on the specific condition and/or individual situation); OR

• Melodic intonation therapy (MIT); OR
• Noncompliance with therapy program; OR
• Psychoneurotic or psychotic conditions; OR
• Self-correcting conditions (e.g., hoarseness or natural dysfluency in young children or developmental articulation errors); OR
• Treatment of speech, language and/or communication deficits/difficulties for the following conditions:

1. Autism spectrum disorders; OR
2. Behavioral disabilities; OR
3. Intellectual disability/intellectual development disorder; OR
4. Learning disabilities; OR
5. Voice training; OR

• When there is no potential for significant improvement documented in the speech evaluation

Speech Therapy Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0324-020
Page: 7 of 16

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition. Note: The criteria for melodic intonation therapy are not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage Determination

Habilitative Speech Therapy

Any state mandates for habilitative speech therapy take precedence over this clinical policy. Refer to specific certificate language regarding habilitative speech therapy. Most certificates limit the duration or number of visits.

General Criteria for Habilitative Speech Therapy

Humana members may be eligible under the Plan for habilitative speech therapy when ALL of the following criteria are met:

• Participating physician or other licensed healthcare professional acting within their state specific licensure has determined that the habilitative speech therapy is expected to result in an improvement or stabilization of the condition within a reasonable and generally predictable period of time; AND
• Habilitative speech therapy may be provided for an individual with a congenital anomaly*, defect or developmental delay** as evidenced by supporting documentation recorded in medical records submitted for review; AND
• Habilitative speech therapy services must be performed by a duly licensed and certified, if applicable, provider. All services provided must be within the applicable scope of practice for the provider in their licensed jurisdiction where the services are provided; AND
• Habilitative speech therapy services provided must be of the complexity and nature to require that they are performed by a licensed speech-language pathologist or provided under their direct supervision by a licensed ancillary person as permitted under state laws; AND

ongoing, written, individualized plan of care that is reviewed with and approved by the treating physician or other licensed healthcare professional acting within their state specific licensure. The plan of care should be of sufficient detail and include appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment. This information should include at least the following:

1. Speech therapy evaluation; AND
2. Frequency and duration of the treatments provided must be reasonable and customary under the generally accepted standards of practice for speech therapy; AND
3. Reasonable estimate as to the time when these goals will be achieved; AND
4. Short- and long-term goals that are specific, quantifiable (measurable) and objective; AND
5. Specific speech therapy techniques, treatments or exercises to be used; AND

Signatures, license numbers and professional license designations of the treating speech-language pathologist and treating physician or other licensed healthcare professional acting within their state specific licensure must be affixed to the evaluation and/or ongoing treatment reports. The individual must be reevaluated at least monthly, and the results of these evaluations recorded in a standard format.

The individual’s progress towards achieving the stated goals must be assessed and if needed, changes made in the treatment program as a result of the evaluations; AND

• Habilitative speech therapy may be appropriate for acute episodes or exacerbations of chronic/longstanding/previously known medical or surgical conditions

Congenital anomaly describes an abnormality of the body that is present from the time of birth.

Speech Therapy Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0324-020
Page: 9 of 16

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Developmental delay describes the condition in which a child is not developing and/or achieving skills according to the expected time frame.

Habilitative speech, language and communication evaluation may be appropriate for the following conditions including, but not limited to:

• Autism spectrum disorders; OR
• Behavioral disabilities; OR
• Intellectual disability/intellectual development disorder (impairments of general mental abilities that impact adaptive functioning from conceptual, social and practical domains); OR
• Learning disabilities

Habilitative speech therapy may be medically necessary in the treatment of communication disabilities and/or dysphagia (swallowing disorders) that are the result of the following conditions including, but not limited to:

• Autism spectrum disorders; OR
• Cerebral anoxia/hypoxia including neonatal asphyxia; OR
• Cerebrovascular accident (CVA); OR
• Congenital anomaly; OR
• Head injury; OR
• Neuromuscular disorders (such as Parkinson’s disease); OR
• Postoperative conditions; OR
• Surgery of the larynx or vocal cords

Note: The criteria for habilitative speech therapy for the treatment of dysphagia are not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Speech Therapy Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0324-020
Page: 10 of 16

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Limitations

Habilitative Speech Therapy

Humana members may NOT be eligible under the Plan for habilitative speech therapy for any indications other than those listed above including, but not limited to, the following:

• Duplicate therapy – receiving multiple therapies (physical, occupational and/or speech therapy) for the same clinical condition. When multiple therapies are used, each must have separate written treatment plans and must provide significantly different treatments and not be seen as generally duplicating each other; OR
• Group therapy (as this is not one-on-one and individualized); OR
• Hearing loss related to the aging process; OR
• Melodic Intonation Therapy (MIT); OR
• Noncompliance with therapy program; OR
• Psychoneurotic or psychotic conditions; OR
• Self-correcting conditions (e.g., hoarseness or natural dysfluency in young children or developmental articulation errors); OR
• Voice training

All other indications are considered not medically necessary as defined in the member’s individual certificate.

Please refer to the member’s individual certificate for the specific definition. Note: The criteria for melodic intonation therapy are not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Background

Additional information about speech disorders (e.g., articulation deficiencies, dysfluencies, voice disorders) may be found from the following websites:

• American Speech-Language Hearing Association
• National Library of Medicine

Speech Therapy Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0324-020
Page: 11 of 16

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.