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.

Speech therapy services may be considered medically necessary when ordered by a physician 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 conditions:

• Primary disorder of speech or hearing related organs, e.g., congenital malformations such as cleft lip/palate, or craniofacial disorders, (this is not an all-inclusive list).
• Secondary disorder impacting speech or hearing, e.g.chronic ear infections, post-stroke, vocal cord lesions or trauma, (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 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.

Habilitative Therapy

Speech Therapy services ordered by a professional provider 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.

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-correcting; 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).

NOTE: Speech Therapy Services are not covered to the extent that the services are or can be provided under the laws of any state or political subdivision (e.g. schools).

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.