MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Speech Therapy

Number 8.03.505

Effective Date February 24, 2014

Revision Date(s) 02/10/14; 01/14/13; 01/06/12; 01/11/11; 08/11/09; 05/13/08; 02/14/06; 05/11/04; 11/12/02; 05/05/97

Replaces N/A

Policy

Speech therapy (ST) services may be considered medically necessary for the treatment of communication impairment or swallowing disorders due to disease, trauma, congenital anomalies, or prior therapeutic intervention.

Speech therapy services are considered not medically necessary for communication dysfunctions that are self-correcting, such as the natural developmental dysfluency or developmental articulation errors that are seen in young children as they learn language.

Duplicate therapy is considered not medically necessary. Patients receiving more than one therapy service, such as occupational and speech therapy, must have separate treatment plans and goals for each therapy.

Non-skilled services (e.g. routine word drills) which do not require the skills and expertise of a qualified provider of speech therapy services are considered not medically necessary.

Maintenance programs for speech therapy are considered not medically necessary.

Related Policies

1.01.502

Augmentative and Alternative Communication Devices/Speech Generating Devices

1.01.518

Stuttering Treatment Devices

8.03.502

Physical Medicine and Rehabilitation – Physical Therapy and Medical Massage Therapy

8.03.503

Occupational Therapy

10.01.500

Skilled Nursing Care in the Home

Policy Guidelines

Speech therapy (ST) sessions must meet ALL of the following criteria:

  • ST is for the needs of a patient who suffers from communication impairment or swallowing disorder due to disease, trauma, congenital anomalies, or prior therapeutic intervention.
  • ST concentrates on achieving specific diagnosis-related goals for a patient who has a reasonable expectation of making measurable improvement in a reasonable and predictable period of time.
  • ST is specific, effective, and reasonable for the patient’s diagnosis and physical condition.
  • ST is delivered by a qualified, licensed provider of speech therapy services. A qualified provider is one who is licensed where required and performs within the scope of licensure.
  • ST interventions require the judgment, knowledge and skills of a qualified provider of speech therapy services due to the complexity and sophistication of the therapy and the physical condition of the patient.

Plan of Care

The plan of care must be established prior to the treatment starting in order for services to be covered and must include:

  • Specific statements of long- and short-term goals;
  • Measurable objectives;
  • A reasonable estimate of when the goals will be reached;
  • The specific treatment techniques and/or exercises to be used in the treatment;
  • The frequency and duration of the treatment.

The plan of care must be updated as the patient’s condition changes and must be recertified by a physician or appropriate treating professional at least every 60 days.

Definition of terms

Duplicate Therapy is when patients receive both occupational and speech therapy. The therapies should provide different treatments and not duplicate the same treatment. They must also have separate treatment plans and goals.

Maintenance (Therapy) Program consists of drills, techniques, and exercises that preserve the patient’s present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved and when no further functional progress is apparent or expected to occur.

  • Services are certain types of treatment do not generally require the skills of a qualified provider of speech therapy services, such as treatments which maintain function by using routine, repetitions, and reinforced procedures that are neither diagnostic nor therapeutic (e.g., practicing word drills for developmental articulation errors) or procedures that may be carried out effectively by the patient, family, or caregivers.

Description

Speech therapy is the treatment of communication impairment and swallowing disorders. Speech therapy services facilitate the development and maintenance of human communication and swallowing through assessment, diagnosis, and rehabilitation.

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer services representative to determine whether there are any benefit limitations applicable to this service or supply. This policy does not apply to Medicare Advantage.

Benefit Application

Speech therapy (ST) must be ordered and the plan of care approved by the member’s attending physician or appropriate treating health care professional. Documentation in the plan of care must support the medical necessity of the ST services. Some health plans may have limited benefits for medically necessary ST.

Rationale

This policy was originally created in 1997 and has been updated based on searches of the MEDLINE database. The most recent literature search was performed through January 23, 2014. The following is a summary of the key findings since the policy was created to date.

A common reason for speech therapy is due to aphasia, a neurological disorder caused by damage to the part of the brain responsible for language. Aphasia is not a disease but is a symptom of brain damage. The most common cause of the damage is a brain attack (stroke) though it can be the result of a brain tumor, infection, head injury or dementia. “It is estimated that about 1 million people in the United States today suffer from aphasia. The type and severity of language dysfunction depends on the precise location and extent of the damaged brain tissue “.(1)

Kelly et al. reported on speech language therapy (SLT) for aphasia following stroke in a Cochrane Systematic Review using the selection criteria of randomized controlled trials (RCTs) comparing SLT vs. no SLT, SLT vs. social support or stimulation, and one SLT intervention vs. another SLT intervention. SLT refers to formal speech and language therapy interventions that strive to improve language and communication abilities in impaired individuals. Language problems following a stroke are called aphasia (or dysphasia). About one-third of all people who experience stroke develop aphasia, which can affect one or more areas of communication (speaking, understanding spoken words, reading and writing). Speech and language therapists are involved in the assessment, diagnosis and treatment of aphasia at all stages of recovery, and work closely with the person with aphasia and their care givers. There is no universally accepted treatment that can be applied to every person with aphasia. The authors identified 30 trials involving 1840 randomised participants that were suitable for inclusion in this review. The authors concluded that overall, the review shows evidence from randomised trials to suggest there may be a benefit from speech and language therapy but there was insufficient evidence to indicate the best approach to delivering speech and language therapy. (2)

Another indication for speech therapy is dysphagia or swallowing disorders where the muscles and nerves used for swallowing are weakened or damaged. A stroke, brain injury, cancer of any of the structures involved in the swallow function or nervous system disorders are some examples of the causes for a swallowing problem. Swallowing disorders may lead to malnutrition, dehydration and/or aspiration. (3) Published clinical trials about specific speech therapy interventions for dysphagia are limited.

Foley et al. reported on a systematic review of randomized controlled trials that evaluated dysphagia treatment post-stroke. Fifteen studies were included that covered a broad range of treatments, including: texture-modified diets, general dysphagia therapy programs, non-oral (e.g., enteral) feeding, medication and physical and olfactory stimulation. There was heterogeneity of the treatments evaluated and the outcomes assessed that precluded the use of pooled analyses. The review reports that general swallowing treatment programs are associated with a reduced risk of pneumonia in the acute stage of stroke. Swallowing therapies and interventions in current practice appear to be based on clinical experience approaches that are physiologically based. The authors concluded that there is a need for high-quality research to identify effective dysphagia treatments post-stroke. (4)

References

  1. National Institute of Neurological Disorders and Stroke (NINDS). NINDS aphasia information page. Last updated July 9, 2012. Available at URL address: http://www.ninds.nih.gov/disorders/aphasia/aphasia.htm. Last accessed January 23, 2014.
  2. Kelly H, Brady MC, Enderby P. Speech and language therapy for aphasia following stroke. (Review). The Cochrane Collaborative. 2010, Issue 7. Available online at URL address: http://www.ucl.ac.uk/clh/events/CD000425.pdf. Last accessed January 23, 2014.
  3. National Institute on Deafness and Other Communication Disorders (NIDCD). Dysphagia information page. Last updated November 24, 2010. Available at URL address: http://www.nidcd.nih.gov/health/voice/Pages/dysph.aspx. Last accessed January 23, 2014.
  4. Foley N, Teasell R, Salter K, Kruger E, Martino R. Dysphagia treatment post stroke: a systematic review of randomised controlled trials. Age Ageing. 2008 May; 37(3):258-64. Available at URL address: http://ageing.oxfordjournals.org/content/37/3/258.long. Last accessed January 23, 2014.

Coding

Codes

Number

Description

CPT

92506

Evaluation of speech, language, voice, communication, and/or auditory processing (deleted effective 12/31/13)

 

92507

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

 

92508

Treatment of speech language, voice, communication, and/or auditory processing disorder; group 2 or more individuals

 

92526

Treatment of swallowing dysfunction and/or oral function for feeding

ICD-9 Procedure

93.72

Dysphasia training

 

93.73

Esophageal speech training

 

93.74

Speech defect training

 

93.75

Other speech training and therapy

ICD-9 Diagnosis

784.3

Aphasia

 

784.41

Aphonia

 

784.49

Other voice disturbance

 

784.5

Other speech disturbance

 

784.69

Other symptoms involving head/neck (code for anomia)

 

787.20

Dysphasia (Note: Policy states due to disease, trauma, congenital anomalies, or prior therapeutic intervention – unable to code, nonspecific.)

HCPCS

G0153

Services of a speech and language pathologist in home health setting, each 15 minutes

 

S9128

Speech therapy, in the home, per diem

 

S9152

Speech therapy, re-evaluation

Type of Service

Medical

 

Place of Service

Inpatient/
Outpatient/
Office

 

Appendix

Definitions of Terms

  • is a communication problem involving trouble with word finding and expressing coherent thoughts.
  • is the inability to produce speech sounds from the larynx, due to paralysis or disease of the pharyngeal nerves.
  • is the inability to perform purposeful movement in the absence of paralysis or other motor or sensory impairment.
  • is impairment of articulation.
  • is speech that is interrupted in its forward flow by hesitations, repetitions, or prolonged sounds; as experienced during normal speech development in young children.
  • is difficulty in swallowing.
  • is impairment of speech consisting of a lack of coordination and failure to arrange words in their proper order.

History

Date

Reason

05/05/97

Add to Therapy Section - New Policy

11/12/02

Replace Policy - Policy reviewed without literature review; new review date only.

05/11/04

Replace Policy - Policy reviewed without literature review; HCPC code added. No change in policy statement.

02/14/06

Replace Policy - Policy reviewed without literature review. Benefit Application revised to delete definition of a “session” due to new guidelines released by Fee Schedule Committee.

06/23/06

Update Scope and Disclaimer - No other changes

09/18/06

Cross References Updated - No other changes.

07/10/07

Cross Reference Update - No other changes.

05/13/08

Replace Policy - Policy updated with literature search; no change to the policy statement. Status changed from AR to BC. Code added.

08/12/08

Cross Reference Update - No other changes.

08/11/09

Replace Policy - Policy updated with literature search; no change to the policy statement.

01/11/11

New PR Policy - Policy updated with literature search; added a statement that the plan of care must be made prior to treatment for services to be covered. Also, the plan of care should be updated every 60 days and as the patient’s condition changes. Policy statement on speech therapy for dysfunctions which are self-correcting has been changed from investigational to not medically necessary. The policy has been converted to a PR policy replacing BC.8.03.04.

01/06/12

Replace Policy – Policy reviewed. No changes.

09/10/12

Update Related Policy – Change titles for 1.01.518 and 1.01.502.

10/26/12

Update Related Policies. Title for 8.03.502 has been changed to say “Medical Massage Therapy”.

01/29/13

Replace policy. Policy guideline updated with addition of the statement “Require the judgment, knowledge and skills of a qualified provider of speech therapy services due to the complexity and sophistication of the therapy and the physical condition of the patient”. Benefit application section has clarifying statement that the plan of care requires orders and approval from an appropriate health care professional. Rationale section updated based on a literature review through November 2012. References 1-4 added. Added definitions to the Appendix section. Policy statement unchanged.

12/23/13

Coding Update. CPT code 92506 discontinued effective 12/31/13.

02/24/14

Replace policy. Moved definition of terms from Benefit Application section to the Policy Guidelines section. A literature search through January 23, 2014 did not prompt the addition of any new references. Policy statements unchanged.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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