Point32 Speech, Language, and Hearing Disorders Form

Harvard Pilgrim HealthCare Medical Policy

Speech, Hearing and Language Services

Subject: Speech, Hearing and Language Services

Authorization:
Authorization is required for outpatient speech/language pathology (SLP) services provided to members enrolled in commercial (HMO, POS, and PPO) products.

• Authorization, duration of authorization, and frequency of re-review are determined by HPHC UM staff.
• Providers are responsible for providing documentation of the member's progress as requested throughout the course of the treatment.

Policy and Coverage Criteria:

Harvard Pilgrim Health Care (HPHC) considers outpatient speech/language pathology (SLP) services necessary to assess and treat communication impairments and swallowing disorders as reasonable and medically necessary, including those resulting from injury, trauma, or medically-based illness. There must be a reasonable expectation that the member will achieve measurable improvement toward diagnosis-related goals within a reasonable and predictable period of time. In addition, covered services must:

• Provide specific, effective, and reasonable treatment for the member's diagnosis and physical condition;
• Require the judgment, knowledge, and skills of a licensed provider due to the complexity and sophistication of the therapy and the physical condition of the member; and
• Be delivered by a licensed provider performing within the scope of his/her licensure.

Outpatient SLP services are covered to the extent described in the individual member's benefit design. Coverage is consistent with applicable state mandates.

General Eligibility Criteria:

Harvard Pilgrim Health Care (HPHC) considers outpatient Speech/Language Pathology (SLP) services as reasonable and medically necessary for members with functional speech, hearing, or language disorders when clinical documentation and supportive testing (as appropriate) confirm ALL the following:

• The member has been diagnosed with a Covered Condition (listed below);
• There is a defined treatment plan (including frequency and duration of services), and plan for monitoring (at regular intervals) the member's progress toward established goals; and
• Long- and short-term goals (described in functional terms) can be attained within a reasonable and predictable period of time.

For school-aged children who require both school-based and outpatient services, there must be evidence that the treating SLP clinician is communicating and collaborating with school (or other) therapists to facilitate optimal member progress.

Requests for authorization of on-going treatment must include evidence of 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 updated long- and short-term goals that are objective, measurable, and attainable within a reasonable and predictable period of time with further treatment.

HPHC Medical Policy

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Speech, Language and Hearing Services

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HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members' unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group.

Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Covered Conditions - Adult and Pediatric

• Dysphagia resulting from: Medical conditions (e.g., CVA, TBI, neurological disease, prematurity); or Oropharyngeal and laryngeal structural abnormalities; Speech/Language Pathology (SLP) services are authorized only when medical record documentation confirms the medical condition, or a structural abnormality adversely impacts his/her ability to safely chew and swallow or move solids or fluids from the mouth down the throat.
• Medical Conditions Impacting Speech or Language Apraxia, or expressive or receptive aphasia resulting from central nervous system injury Dysarthria from central or peripheral nervous system injury (e.g., CVA, TBI, CP, Parkinsonism, MS, ALS, Myasthenia Gravis) Poor speech intelligibility due to oral/pharyngeal structure abnormalities (e.g., partial or total glossectomy) SLP services are authorized when medical record documentation confirms a reasonable expectation of significant improvement(s) in a reasonable and generally predictable period of time.
• Cough Muscle Tension Dysphonia
• Puberphonia/ Mutational Falsetto
• Spasmodic Dysphonia
• S/P Laryngectomy- Partial or Total Vocal cord dysfunction (i.e., laryngospasm or Paradoxical Vocal Fold Movement/PVFM) Vocal cord paralysis/paresis/hypomobility Vocal fatigue Vocal Tremor
• Dysphoria Refer to the_ Gender Affirming Medical Policy for clinical coverage criteria for voice modification and

HPHC Medical Policy

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Speech, Language and Hearing Services

VD16NOV22PV

HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group.

Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Condition - Age Years) Criteria

• Articulation/Phonological Processing Disorders
  SLP services are authorized when medical record documentation confirms member has at least two phonological processes that are not developmental-age appropriate; AND EITHER of the following:
  Fair to poor intelligibility (i.e., it is difficult for the listener to understand when the child speaks in words, sentences, or conversation); OR
  Good intelligibility but errors (e.g., distortions, substitutions, omissions) are atypical or not age appropriate.
• Autism Spectrum Disorders (ASD) Pervasive Developmental Disorders (PDD)
  SLP services are authorized for assessment and treatment of ASD/PDD when medical record documentation confirms ANY of the following:
  Loss of any language or social skills at any age;
  No babbling by age 12 months;
  No gesturing (e.g., pointing, waving bye-bye) by age 12 months;
  No single words by age 16 months;
  No two-word spontaneous phrases (not just echolalic) by age 24 months.
• Childhood Apraxia of Speech
  SLP services are authorized when medical record documentation confirms member has ALL:
  Difficulty with sequencing sounds, syllables and words; AND
  Poor intelligibility measured using a standard tool.
• Cleft Lip/Cleft Palate
  SLP services are authorized when the attending physician or surgeon determines services are medically necessary and consequent to the treatment of cleft lip and/or cleft palate.
• Developmental Language Delays
  SLP services are authorized when medical record documentation confirms a delay in receptive, expressive, or pragmatic language:
  Significantly impacts the child's ability to effectively communicate his/her wants and needs; OR
  Significantly impacts the child's ability to be understood by family/caregivers (i.e., patient scores at or below the 16th percentile on standardized measures).

Dysfluency/Stuttering
Dysfluency/Stuttering requests are reviewed on a case by case basis.

HPHC Medical Policy      Page 3 of 5

Speech, Language and Hearing Services

VD16NOV22PV

HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group.

Tongue Thrust Swallow Pattern

Reviewed on a case by case basis. Factors including member/family motivation, and member needs are considered. Improvements are expected within four visits (in most cases); re-evaluation is required before additional visits are authorized.

Additional visits are not authorized if there is no objective evidence of progress after four visits.

Post Cochlear Implant SLP services are authorized when medical record documentation confirms progress towards established goals, and member/family compliance with outpatient treatment plan (including consistent attendance) and home carryover.

Exclusions:

Harvard Pilgrim Health Care (HPHC) considers speech, hearing and language services as not medically necessary for all other indications. In addition, HPHC does not cover:

• Maintenance activities intended to preserve the member's present level of function or prevent regression of that function; or
• Educational/school-based services that are not part of a defined medical treatment plan for disorders resulting from injury, trauma, or medically-based illness or disease.
• School-based services, or services that are primarily academic or educational in nature (e.g., services to enhance writing skills), and not part of a defined medical treatment plan.
• SLP services requested for psychosocial, behavioral, or conceptual problems encountered in school settings (including speech or developmental delays, and/or attention disorders) when services are not part of a defined medical treatment plan.
• Outpatient SLP services for disorders that are self-correcting (e.g., natural dysfluency or developmental articulation disorders in young children).
• 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).

HPHC Medical Policy
Page 4 of 5

Speech, Language and Hearing Services

VD16NOV22PV

HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members' unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

SLP services designed to preserve present level of function or prevent regression after therapeutic goals of the treatment plan have been achieved, or in situations where no further functional progress is apparent or expected to occur.

SLP services for treatment of dialect and accent reduction, or whose purpose is vocationally or recreationally based.