Speech therapy is the treatment of communication impairment and swallowing disorders (dysphagia). Speech therapy services involve the use of special techniques to facilitate the development and maintenance of human verbal communication and swallowing through assessment, diagnosis, and rehabilitation. This includes voice therapy, which is the treatment of communication impairment resulting from the vocal cords or laryngeal structures.

Adult Speech Therapy

Speech therapy services may be considered medically necessary when ordered by a physician, physician assistant or nurse practitioner and performed by a licensed speech pathologist/therapist. Speech therapy services must be directed to the active treatment of at least ONE of the following disorders:

• Apraxia; or
• Dysathria; or
• Aphasia; or
• Dysphagia

AND

The disorder is related to ONE of the following medical conditions:

• Dementia; or
• Right hemisphere brain injury; or
• Traumatic brain Injury; or
• Stroke; or
• Brain tumor; or
• Progressive neuromuscular disease ( e.g.,amyotrophic lateral sclerosis, Huntington’s disease, multiple sclerosis or muscular dystrophy). (This is not an all-inclusive list).

Voice therapy may be considered medically necessary for ANY of the following conditions (this is not an all-inclusive list):

• Closed head trauma; or
• Laryngeal trauma and trauma related dysphonia’s; or
• Polyps; or
• Vocal Cord Lesions; or
• Vocal Cord Paralysis or Paresis; or
• Vocal Cysts; or
• Vocal nodules. 

NOTE: Voice therapy provided prior to surgery is not a covered service.

Speech therapy services must achieve a specific diagnosis-related goal for an individual who has a reasonable expectation of achieving measurable improvement in a predictable period of time. These services must also provide specific, and effective treatment for the individual’s diagnosis and physical condition.

Speech therapy should be provided in accordance with an ongoing, written therapy plan.

NOTE: Neuromuscular electrical stimulation where a small current is passed through external electrodes placed on the neck to stimulate inactive or atrophied swallowing muscles may be considered medically necessary as an adjunct to treatment techniques and exercises.

Speech therapy services not meeting the criteria as indicated in this policy are considered not medically necessary.

Pediatric Speech Therapy

Speech Therapy for children may be considered medically necessary when ordered by a physician, physician assistant or nurse practitioner and performed by a licensed speech pathologist/therapist. Speech therapy services must be directed to the active treatment of at least ONE of the following disorders:

• Dysarthria; or
• Speech sound disorders (articulation disorder, phonological disorder); or
• Language disorders or delays (expressive language disorder, mixed receptive/expressive language disorder).

AND

The disorder is related to ONE of the following medical conditions or developmental disorders:

• Structural anomalies (e.g., cleft lip/palate, macroglossia, or velopharyngeal insufficiency. (This is not an all-inclusive list); or
• Intellectual disability resulting from a genetic disorder (e.g., trisomy 21 or fragile X syndrome), autism or an unknown cause. (This is not an all-inclusive list);  or
• Neonatal disorders such as prematurity (32 weeks EGA or less), hypoxic-ischemic encephalopathy, intraventricular hemorrhage, or intrauterine/neonatal stroke. (This is not an all-inclusive list); or
• Sensory disorders such as hearing loss; or
• Developmental speech or language disorders that are moderate-to-severe (>1 SD below the mean for age) and ONE or more of the following:

o   Documented to have a significant impact of the child’s ability to communicate; or

o   Persist beyond eight (8) years of age.

NOTE: Chronic ear infections must be of such documented severity and duration that the development of speech/language skills can be shown to be impaired. Generally, a bilateral hearing loss of 40dB of sufficient length (generally three (3) months) during the speech/language formative period (prior to the age of four (4)) is adequate for the coverage of these services.

Speech Therapy for children with fluency disorders may be considered medically necessary when ordered by a physician, physician assistant or nurse practioner  and performed by a licensed speech pathologist/therapist when at least ONE of the following features is present:

• Signs of tension (blocks, facial grimacing); or
• Prolongation of sounds: or
• Repeating sounds/syllables (as opposed to whole words/phrases):  or
• Symptoms began at age four (4) or above; or
• Symptoms have been present for more than six (6) months. 

Speech therapy for children with swallowing disorders (dysphagia) may be considered medically necessary if the child has a diagnosis of dysphagia or confirmed aspiration that requires speech therapy to correct or mitigate.

Speech therapy for children with problems that do not involve swallowing dysfunction (e.g., sensory food aversion or avoidant/restrictive food aversion) are considered not medically necessary.

Pediatric voice therapy may be considered medically necessary for ANY of the following conditions (this is not an all-inclusive list):

• Closed head trauma; or
• Laryngeal trauma and trauma-related dysphonia; or
• Polyps; or
• Vocal cord lesions; or
• Vocal cord paralysis or paresis; or
• Vocal cysts; or
• Vocal nodules; or
• Velopharyngeal insufficiency; or
• Upper airway obstruction.

NOTE: Voice therapy provided prior to surgery is not a covered service.

Speech therapy services must achieve a specific diagnosis-related goal for an individual who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time. These services must also provide specific, effective, and reasonable treatment for the individual’s diagnosis and physical condition.

Speech therapy should be provided in accordance with an ongoing, written therapy plan.

NOTE: Neuromuscular electrical stimulation where a small current is passed through external electrodes placed on the neck to stimulate inactive or atrophied swallowing muscles may be considered medically necessary as an adjunct to treatment techniques and exercises.

Speech therapy services not meeting the criteria as indicated in this policy are considered not medically necessary.

Habilitative Therapy

Speech Therapy services ordered by a physician, physician assistant or nurse practitioner to promote the restoration, maintenance, or improvement in the level of function following disease, illness or injury. This also includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.

The treatment plan should be maintained in the medical record and include the following:

• Specific statements of long- and short-term goals; and
• Measurable objectives; and
• A reasonable estimate of when the goals of therapy will be reached; and
• A description of the specific treatment techniques and/or exercises to be used in the treatment; and
• The frequency and duration of the treatment; and
• The individual should be re-evaluated at a minimum frequency of every 12 months.

The following services are not covered:

• Therapy provided in an in-patient setting if speech therapy was the sole reason for the hospitalization; and
• Therapy that is considered primarily educational; and
• Services that do not require the skills of a qualified provider of speech therapy including those that can be effectively provided by the individual, family, or caregivers as well as those treatments that maintain function using routine, repetitious, and/or reinforced procedures that are neither diagnostic nor therapeutic (e.g., practicing word drills for developmental articulation errors); and
• Speech therapy services for dysfunctions that are self-correcting, such as language therapy for young children with natural dysfluency or developmental articulation errors that may be self-correctingand
• Speech therapy services for developmental speech or language delays/disorders one standard deviation (SD) or less below the mean in the areas of receptive, expressive, pragmatic or total language composite score; and
• Services that duplicate those provided by physical or occupational therapists. (Therapists should provide different treatments that reflect each therapy discipline's unique perspective on the individual's impairments and functional deficits and not duplicate the same treatment. They must also have separate evaluations, treatment plans, and goals).

Maintenance Therapy

Speech Therapy services performed repetitively to maintain a level of function is not eligible for payment unless the individual has Habilitative Services benefits. A maintenance program consists of activities that preserve the individual’s present level of function and prevent regression of that function. These services generally would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Maintenance therapy (physical or manipulative therapy performed for maintenance rather than restoration), is not eligible for payment.