Oscar Home Care - Speech Language Pathology (CG023) Form

Members recently discharged from the hospital

and/or those diagnosed with certain medical conditions may require short-term skilled care in the home for rehabilitation. When medically necessary, such services can be used to restore or improve functional independence, and help train caregivers and family members in ongoing care of the member.

Speech Language Pathology (SLP) or Speech Therapy services

are an example of skilled home care and when medically necessary, can be used to improve or restore functional skills of communication (speech production, fluency, language, cognition, voice, resonance, and hearing) and swallowing (oral, pharyngeal, and esophageal, including related feeding behaviors).

Speech therapy is appropriate for specific disorders that affect communication, swallowing, and cognition. A communication disorder as per American Speech-Language-Hearing Association is an impairment in the ability to receive, send, process, and comprehend verbal, nonverbal or symbolic based information. Communication disorders can include speech disorders such as articulation, fluency, or voice, a language disorder including the form (rules that govern how sounds and words are structured), content (meaning of words and sentences) or function (pragmatic/social) of language and hearing disorders including deaf and hard of hearing.

Examples of disorders that affect communication

• chronic otitis media with conductive hearing loss,
• vocal cord injuries and/or conditions (e.g., edema, nodules, growths),
• stroke or cerebrovascular accident (CVA),
• injury or trauma,
• cerebral palsy, or encephalopathy.

Signs of feeding and swallowing disorders may include: difficulty sucking, biting/chewing, moving foods within the mouth, taking a long time to eat, coughing or gagging during meals, having a gurgly, hoarse, or breathy voice during or after meals, or are losing weight or not gaining weight or growing. Swallowing disorders may result from stroke or cerebrovascular accident (CVA), traumatic brain injury (TBI), cancer, congenital defect, certain genetic syndromes, or certain neurodegenerative disorders such as Parkinson disease (PD), or amyotrophic lateral sclerosis (ALS).

Signs of a change in cognition can include reduced awareness and ability to communicate wants and needs, reduced memory, judgment, and ability to share information, reduced ability in problem solving, reasoning, or judging potential consequences.

Speech pathology is generally coordinated by a multidisciplinary team of licensed speech language pathologists, nurses, and prescribing clinicians. Treatments may consist of activities that are tailored to address the functional needs of the member in their own environment. These skilled interventions focus on improving speech, language production, cognitive function, and swallowing. Home SLP therapy requires a prescription and clear documentation of progress, goals, and ongoing medical necessity.

Information about coverage and benefit limitations can be found in the member's plan contract at hioscar.com/forms.

Definitions

"Homebound" refers to members who have normal inability to leave home without considerable and taxing effort (i.e., requires an assistive device or the assistance of another person to leave home) AND one of the following:

• Members who cannot leave home due to a medical condition, chronic disease, or injury; or
• Members advised by a treating provider not to leave home for various reasons (e.g., safety, ongoing medical treatment needs, etc. ); or
• Members who need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, special transportation (when the member is unable to use common transportation such as private automobile, bus, taxi due to medical condition), or the assistance of others to leave their place of residence.

When the member does leave home, the absence of the member from the home is infrequent or for short periods of time, such as to receive health treatment or adult daycare (non-residential program providing services during the day).

"Speech Language Pathology (SLP)" Therapy or "Speech Therapy" encompasses the diagnosis and treatment of communication and swallowing:

1. Communication:
• Cognitive deficits include problems with memory, executive functioning, attention, problem solving, decision making, organization of thoughts and ideas, and visuospatial processing.
• A hearing disorder can include hearing loss, deafness, and auditory processing.
• A language disorder consists of impaired comprehension and/or use of spoken, written, or other symbolic systems. It can include difficulty with phonology, morphology, syntax, semantics, pragmatics, vocabulary, and word retrieval, including receptive and expressive aphasias.
• A speech disorder is an impairment of the articulation of speech sounds, fluency, and/or voice. It may include deficits such as problems with perception, motor or vocal production articulation, and phonology.
• A fluency disorder includes an interruption in the flow of speaking characterized by atypical rate, rhythm, and disfluencies (e.g., repetitions of sounds, syllables, words, and phrases; sound prolongations; and blocks), which may also be accompanied by excessive tension, speaking avoidance, struggle behaviors, and secondary mannerisms.
• An articulation disorder is the atypical production of speech sounds characterized by substitutions, omissions, additions, or distortions that can impact how well a person is understood.
• A voice disorder is characterized by abnormal production of vocal quality, pitch, loudness, and resonance which is not appropriate for an individual’s age or gender. Voice disorders can be caused by vocal cord injuries and conditions (e.g., edema, nodules, growths) resulting in conditions that affect voice quality, pitch, and loudness ranging from aphonia to hoarseness.
• A resonance disorder is a deficit in resonance attributed to having too much or too little nasal and/or oral sound energy in the speech signal.

They can result from structural or functional (e.g., neurogenic) causes and occasionally are due to mislearning (e.g., articulation errors that can lead to the perception of a resonance disorder). Resonance disorders include hypernasality, hyponasality, cul-de-sac resonance or mixed resonance.

Swallowing

A feeding and swallowing disorder or dysphagia is characterized by difficulty moving food or liquid from the mouth (oral cavity), throat (pharynx), or esophagus to the stomach. Dysphagia can occur in the oral, pharyngeal, or esophageal stages.

"Speech Language Pathologists (SLPs)" work to prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing disorders in children and adults. This treatment should be delivered by a licensed and certified speech language pathologist.

"Activities of Daily Living (ADLs)" are defined as routine activities that most healthy persons perform daily without requiring assistance: These include but are not limited to: communication and eating.

"Instrumental Activities of Daily Living (IADLs)" are defined as activities that may be performed daily but are not fundamental for daily functioning. These include, but are not limited to: the use of public transportation, balancing a checkbook, community living activities, meal preparation, laundry, leisure activities and sports, and motor vehicle operation.

"Rehabilitative Treatments" are healthcare services and devices with the goal of helping a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired due to illness, injury, or disability.

"Habilitative Treatments" are healthcare services and devices with the goal of helping a person keep, learn, or improve skills and functioning for daily living when they are impaired as a result of injury, disease, or congenital abnormality. This is different from rehabilitative treatment in that habilitative treatments are for individuals that have not developed to the expected level of function or have not yet met a development milestone; an example includes therapy for a child who is not talking at the expected age.

"Custodial Care" or "Long-term Care" are non-skilled, personal care to maintain the member's ADLs or IADLS over a long-term duration and do not require oversight or skilled services by trained health professionals or technical personnel. These services are not part of a medical treatment plan for recovery, rehabilitation, habilitation, or improvement in sickness or injury. Custodial services may be provided in the home, assisted living facilities, or nursing homes, etc. This type of custodial or long-term care typically does not apply for plan benefits, please see the member's plan benefit.

Hospice Care / End-of-Life Care - are interdisciplinary and holistic care when curative or life-prolonging treatments are no longer beneficial and services may focus on symptom control, psychosocial and spiritual care, nursing, or short-term acute services. Trained clinicians and support staff support individual and family quality-of-life goals. Hospice care can be provided in the home, skilled nursing facility, or hospital setting (for acute symptom management and stabilization to return to previous level of hospice care).

Palliative Care - is interdisciplinary and holistic care that focuses on symptom management, relieving suffering in all stages of disease, supporting communication, assessing psychosocial and spiritual resources, social and economic resources. Members may receive curative or life-prolonging treatment, and may not choose to receive hospice care or end-of-life care. Furthermore, palliative care provides support for individual and family quality-of-life goals.

Clinical Indications

Speech Language Pathology services in the home are considered medically necessary for initial requests when ALL of the following criteria are met:

1. The treatment plan is prescribed by a licensed provider (MD, DO, NP, or PA) as per individual state law and must be provided by a licensed SLP therapist certified by ASHA (American Speech Language Hearing Association); and
2. The member meets the definition of homebound (see Definitions section above); and
3. Medical necessity criteria in the appropriate MCG Home Care Optimal Recovery Guidelines or MCG Home Care General Recovery Guideline is met; and/or
4. For members requesting hospice care/end-of-life care or palliative care (please check plan benefits to verify hospice or palliative care benefit timeframes), the following criteria must be met to meet medical necessity:
   • The member is terminally ill, presenting with functional decline, and certified by a medical practitioner for life expectancy less than twelve months for palliative care and less than six months for hospice/end-of-life care; and
   • The SLP services are rendered as part of a hospice care program; and
   • The member may receive curative treatment while receiving palliative care; and/or
   • The member is not receiving curative treatment while in hospice care; and
5. The member is motivated, alert and oriented (unless member has cognitive impairment and may not be fully oriented); and
6. Therapy is aimed at establishing or restoring function; and
7. Rehab potential is evident based on a review of the member's condition, and the member's function is not expected to improve in the absence of therapy; and
8. The written plan of care should be sufficient to determine the necessity of SLP therapy and must include the following elements:
   • A medical evaluation has been conducted within 30 days of the service dates; and
   • The diagnosis, the date of onset or exacerbation of the disorder/diagnosis, the duration, the severity, the anticipated course (stable, progressive or, improving), and the prognosis; and
   • Prior level and current level of communication (including any prior device usage); and
   • Standardized testing applicable to the member's age and medical condition; and

9. Documentation of medical necessity should be reviewed when ANY of the following occur:
   • The plan of care exceeds the expected duration and/or estimated frequency of care; or
   • There is a change in the member’s condition that may impact the plan of care; or
   • The specific goals are no longer expected to be achieved in a reasonable or expected duration of time.

Additional Qualifying Criteria for Dysphagia and Vocal Therapy

SLP therapy indicated for dysphagia must also meet the following criteria:

1. The member is at high risk of recurrent aspiration/choking and inadequate nutrition and hydration as evidenced by the results of a videofluoroscopic swallowing study (VFSS), i.e., modified barium swallow study (MBSS), or fiberoptic endoscopic evaluation of swallowing (FEES); and
2. The member has retained some swallowing function and shows stimulability to improve swallowing safety and efficiency in therapy as evidenced by the results of an VFSS, MBSS or FEES.

SLP therapy indicated for vocal therapy is appropriate only for the following conditions and must include an ENT evaluation; if available and physically possible, a videostroboscopy should be conducted:

1. Vocal cord dysfunction (paradoxical vocal cord motion); or
2. Spastic dysphonia; or
3. Vocal cord nodules; or
4. Vocal cord paralysis; or
5. Following laryngeal cancer; or
6. Following surgery or injury to the vocal cords.

Extension Requests

A Plan member who requires continued SLP visits, beyond the original treatment plan of care, may receive extended treatment when the following criteria are met:

1. A re-evaluation has been conducted within 30 days of the service dates; and
   • The appropriate MCG Home Care Optimal Recovery Guidelines with the Extended Visits criteria are met; or
   • The appropriate MCG Home Care General Recovery Guideline and the member is still in General Treatment Course Stage 2 or has not met all of the milestones in Stage 3; or
2. For an extension request/recertification for hospice or palliative care, please see plan benefits and requirements.

Experimental or Investigational / Not Medically Necessary

Skilled home care, and thus home SLP therapy, should be discontinued when one of the following is present:

• Homebound status is no longer met; or
• The member reaches the predetermined goals or skilled treatment is no longer required; or
• The member has reached maximum rehab potential; or
• The goals will not be met and there is no expectation of meeting them in reasonable time; or
• The member can safely and effectively continue their rehabilitation independently or with the help of family or caregivers; or
• The member’s medical condition prevents further therapy; or
• The member refuses treatment; or
• The member’s behavior or home environment is deemed to be unsafe for effective therapeutic intervention

SLP services are not considered medically necessary for the following:

• Asymptomatic members or those without an identifiable clinical condition; or
• Cases of transient or easily reversible loss or reduction in function which could be reasonably expected to improve spontaneously as the member gradually resumes normal activities; or
• Chronic illness / chronic flare-ups or exacerbations that did not result in a decline in function or related to an acute exacerbation, or
• Long-term maintenance therapy, as it is aimed to preserve the present level of function or to prevent regression below an acceptable level of functioning; or
• Custodial care or Long-term care services; or
• No expected improvement in functioning over a reasonable and predictable period of time (i.e., a "stable deficit"); or
• Duplicative therapy services or programs; or
• Treatment modalities that do not require a skilled professional speech language therapy and can safely be conducted by the member alone or with the help of family or caregivers;or
• Occupational or recreational requests aiming to augment or improve upon normal human functioning; this includes services considered as routine, conditioning, educational, employment or job training, or as part of a voice training program for singing, public speaking, or fitness; or
• Services aimed to identify or screen for members, including screening for hearing acuity; or

● As a component of auditory rehab, except for a newly prescribed auditory device (e.g., cochlear implant or BAHA); or

● Treatment modalities for which SLP is not adequately supported by peer-reviewed literature include, but are not limited to:

• Facilitated communication
• Altered auditory feedback devices
• Auditory verbal therapy
• Vital stim or equivalent electrical stimulation for swallowing disorders
• Sequential Oral Sensory (SOS) or equivalent therapy
• Voice amplifiers in the absence of illness or injury do not meet DME requirements; or

● Conditions for which SLP is not adequately supported by peer-reviewed literature include, but are not limited to:

• Transient ischemic attacks (TIAs), as they are a transient and self-limited deficit.
• Essential voice tremor
• Laryngeal hyperadduction
• Laryngitis
• Functional dysphonia
• Supraglottic vocal hyperfunction
• Altered auditory feedback devices / communication aids for stuttering
• Members with developmental articulation errors that are self-correcting (e.g., word drills)
• Sign language training as an augment to primary spoken language
• Myofunctional disorders (e.g., tongue thrust)
• Chronic conditions flare-ups or exacerbations without acute exacerbation that do not meet the above criteria
• Idiopathic speech delays in members younger than 18 months old is considered experimental as it is unreliable to diagnose speech delays
• Functional feeding disorders