Speech Therapy - Cigna
Medical Coverage PolicyEffective Date .12/15/2020Next Review Date.12/15/2021Coverage Policy Number . 0177Speech TherapyTable of ContentsRelated Coverage ResourcesOverview . 1Coverage Policy.1General Background .4Medicare Coverage Determinations .17Coding/Billing Information .17References .18Attention-Deficit/Hyperactivity Disorder (ADHD):Assessment and TreatmentAutism Spectrum Disorders/Pervasive DevelopmentalDisorders: Assessment and TreatmentCochlear and Auditory Brainstem ImplantsCognitive RehabilitationElectric Stimulation for Pain, Swelling and Function ina Clinic SettingElectrical Stimulation Therapy and Home DevicesNutritional SupportOccupational TherapyOutpatient Acute RehabilitationPediatric Intensive Feeding ProgramsSensory and Auditory Integration TherapyFacilitated CommunicationSpeech Generating DevicesStuttering Treatment DevicesINSTRUCTIONS FOR USEThe following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines ofbusiness only provide utilization review services to clients and do not make coverage determinations. References to standard benefit planlanguage and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpretingcertain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document[Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] maydiffer significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plandocument may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefitplan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coveragemandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specificinstance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicablelaws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particularsituation. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations fortreatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to supportmedical necessity and other coverage determinations.OverviewThis Coverage Policy addresses speech therapy services including speech therapy, voice therapy,swallowing/feeding therapy and aural/auditory rehabilitation.Coverage PolicyUnder many benefit plans, coverage for outpatient speech therapy and speech therapy provided in thehome is subject to the terms, conditions and limitations of the Short-Term Rehabilitative Therapy benefitPage 1 of 25Medical Coverage Policy: 0177
as described in the applicable benefit plan’s schedule of copayments. Swallowing/feeding therapy isconsidered a form of speech therapy.Outpatient speech therapy is the most medically appropriate setting for these services unless theindividual independently meets coverage criteria for a different level of care.Coverage for speech therapy varies across plans. Refer to the customer’s benefit plan document forcoverage details.If coverage is available for speech therapy, the following conditions of coverage apply.Speech/Language TherapyA prescribed course of speech therapy for the treatment of a speech/language impairment or for the useof a speech-generating device (CPT code 92609) is considered medically necessary when ALL of thefollowing criteria is met: When accompanied by an evaluation completed within the last 12 months by a certified speechlanguage pathologist that includes age-appropriate standardized tests or measures that quantify theextent of language/speech impairment, performance deviation, or pragmatic skill deficits.The therapy plan includes quantifiable, attainable short- and long-term treatment goals against whichprogress will be documented.The treatment being recommended has the support of a treating licensed healthcare provider (e.g.,referral, prescription).The therapy being ordered requires the one-to-one intervention and supervision of a speech-languagepathologist.The therapy is individualized, and meaningful improvement is expected from the therapy.Continuation of speech therapy visits is considered medically necessary when ALL of the followingcriteria are met: There is documented quantifiable improvement towards established short and long-term treatmentgoals.Functional progress is being made.Generalization and carryover of targeted skills into natural environment is occurring.Goals of therapy are not yet met.Individual is actively participating in treatment sessions.Voice TherapyA prescribed course of voice therapy is considered medically necessary when provided by a certifiedspeech-language pathologist for a significant voice disorder associated with the laryngeal structuresthat are associated with anatomic abnormality, neurological condition, injury (e.g., vocal nodules orpolyps, vocal cord paresis or paralysis, paradoxical vocal cord motion) or provided after vocal cordsurgery when ALL of the following criteria are met: The treatment being recommended has the support of a licensed healthcare provider (e.g., referral,prescription).The therapy being ordered requires the one-to-one intervention and supervision of a speech-languagepathologist. The therapy plan includes quantifiable, attainable short- and long-term treatment goals against which progress willbe documented. The therapy is individualized, and meaningful improvement is expected from the therapy.Page 2 of 25Medical Coverage Policy: 0177
Continuation of voice therapy is considered medically necessary, as indicated by ALL of the following: Functional progress is being madeGeneralization and carryover of targeted skills into natural environment is occurringGoals of therapy are not yet metIndividual is actively participating in treatment sessionsAuditory/Aural RehabilitationAuditory/aural rehabilitation (CPT code 92630, 92633) is considered medically necessary for thetreatment of a hearing impairment that is the result of trauma, tumor or disease, or followingimplantation of a cochlear or auditory brainstem device when ALL of the following criteria are met: The treatment being recommended has the support of a treating licensed healthcare provider (e.g.,referral, prescription).An evaluation has been completed by a certified speech-language pathologist or licensed audiologistthat includes standardized speech and/or hearing tests.The therapy plan includes quantifiable, attainable short- and long-term treatment goals against whichprogress will be documented.The therapy being ordered requires the one-to-one intervention and supervision of a speech-languagepathologist or audiologist.The therapy is individualized, and meaningful improvement is expected from the therapy.Swallowing/Feeding TherapySwallowing/feeding therapy is considered medically necessary for individuals with swallowing andchildren with a feeding disorder when ALL of the following criteria are met: The swallowing or feeding disorder is the result of an underlying medical condition.The medical necessity of the therapy has been demonstrated by results of testing with avideofluorographic swallowing study (VFSS) or other appropriate testing in combination with anevaluation by a certified speech-language pathologist.The therapy plan includes quantifiable, attainable short- and long-term treatment goals against whichprogress will be documented.The treatment includes a transition from one-to-one supervision to an individual or caregiver providedmaintenance level on discharge.Not Medically NecessaryThe following are considered not medically necessary: 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 languagecomposite scoreany computer-based learning program for speech or voice training purposes unless used for utilization ofan approved speech generating devicespeech therapy services that are educational learning services such as reading, writing, and spellingwithout evidence of a documented spoken language disorderschool speech programsspeech, voice therapy, auditory/aural rehabilitation or swallowing/feeding therapy that duplicatesservices already being provided as part of an authorized therapy program through another therapydiscipline or speech therapy (e.g., occupational therapy; audiologic services)maintenance programs of routine, repetitive drills/exercises that do not require the skills of a speechlanguage therapist and that can be reinforced by the individual or caregiverPage 3 of 25Medical Coverage Policy: 0177
vocational rehabilitation programs and any programs with the primary goal of returning an individual toworktherapy or treatment provided to prevent or slow deterioration in function or prevent reoccurrencestherapy or treatment intended to improve or maintain general physical conditiontherapy or treatment provided to improve or enhance job, school or recreational performancelong-term rehabilitative services when significant therapeutic improvement is not expected (e.g., whenthere is therapeutic plateau)swallowing/feeding therapy for food aversionsvoice therapy in the absence of an anatomic laryngeal abnormality (e.g., functional dysphonia,spasmodic dysphonia)auditory/aural rehabilitation for presbycusisElectrical stimulation for swallowing/feeding disorders is considered experimental, investigational orunproven.General BackgroundSpeech therapy is the treatment of defects and disorders of speech and language disorders. Prior to the initiationof speech therapy, a comprehensive evaluation of the patient and his or her speech and language potential isgenerally required before a full treatment plan is formulated. As part of the evaluation, standardized assessmenttests should be used for evaluations to identify and quantify impairment and may include the following (Kortteand Palmer, 2008): Receptive-Expressive Emergent Language Scale (REEL): infants (birth to three years)Test of Language Development (TOLD): school-age childrenPorch Index of Communication Ability (PICA): adultsBoston Diagnostic Aphasia Examination: adultsPeabody Picture Vocabulary Test (PPVT): for all agesFor the child with a speech delay, the speech/language evaluation may demonstrate that the potential existsthat, through speech therapy, the child will reach an age-appropriate level of speech. Some situations for whichspeech therapy may be appropriate in the prelingual child include: following documented central nervous systemanoxia and/or long-term intubation, chronic otitis media, or after cochlear implant or cleft palate surgery.A hearing test may also be conducted to determine if the child is experiencing mild hearing loss as a result oftransient or persistent ear infections or allergies. Should these conditions be identified, then medicalmanagement and monitoring should be used to minimize the effects that this could have on future languagelearning. Comorbid psychiatric disorders, environmental deprivation, pervasive developmental disorders,intellectual disability, autism and selective mutism should all be considered in cases of language delay (Koyama,et al., 2009).Speech therapy services should be individualized to the specific communication needs of the patients. It shouldbe provided one-to-one by a speech-language pathologist educated in the assessment of speech and languagedevelopment, the treatment of language and speech disorders. A speech-language pathologist can offer specificstrategies, exercises and activities to regain functional communication abilities (Kortte and Palmer, 2008).Continuation of Speech TherapyBefore continuing speech/language services, the results of these patient-specific measures goals shoulddemonstrate that the individual is consistently improving, that there is functional progress and that a plateau (i.e.,where no additional meaningful improvements are being measured or are expected to occur) has not beenreached. There should be documented progress toward the measurable goals for additional visits to beconsidered medically necessary. Once the individual has reached their goals or a therapeutic plateau has beenreached, then ongoing therapy becomes maintenance in nature. Maintenance services are intended to preservethe individual’s present level range, strength, coordination, balance, pain, activity, function, etc. and preventPage 4 of 25Medical Coverage Policy: 0177
regression of the same parameters. Maintenance begins when the therapeutic goals of a treatment plan havebeen achieved, or when no additional functional progress is apparent or expected to occur (ASHA, 2015).Functional progress may be demonstrated in the documentation by improving communication skills which mayinclude: improving ability to express coherent thoughts effectively improving direction-following and understanding/asking of questions improving expressive and receptive vocabulary improving linguistic memory of information read or heard improving oral and written grammar and syntax improving pragmatic language skills, including verbal and nonverbal language Improving preliteracy or literacy skills, improving receptive and expressive language for both oral andwritten language. increasing expressive utterance length and complexityGroup TherapyGroup therapy sessions should meet criteria for an individualized plan of treatment, and group therapy shouldalso be medically necessary and should include (CMS, 2019): services are rendered under an individualized plan of care the group has no more than four group members group therapy does not represent the entire plan of treatmentWhen group therapy is provided the documentation for group therapy should clearly identify why services weredelivered in a group setting; establish that group therapy services were provided as part of an individualized planof care; demonstrate that services were based on the clinical needs of the patient; and describe goals andoutcomes (e.g., improvement in the patient’s condition, prevention of further decline). Group therapy shouldnever be provided for the convenience of the clinician or facility (ASHAe).Duplication of ServicesServices that are provided by speech therapists and other providers (e.g., occupational therapy, audiology) mayoverlap (Houtrow, et al., 2019). Speech therapy that is being provided as part of an occupational trainingprogram is considered duplicative in nature. When different providers, including two speech therapists, areproviding services there should be separate treatment plans and goals and should not duplicate the services.When multiple therapies are used, each must have separate written treatment plans and must providesignificantly different treatments and not be seen as generally duplicating each other’s treatment.Speech-Language PathologistA speech-language pathologist (SLP) has a master’s or doctoral degree and is licensed, if applicable, as aspeech-language pathologist by the state in which he or she is practicing. The SLP possesses a Certificate ofClinical Competence (CCC) from the American Speech-Language-Hearing Association (ASHA) or has met allthe educational requirements leading to the CCC, and is in the clinical fellowship (CF) year or is otherwiseeligible for the CCC (American Speech-Language-Hearing Association, 2011).Speech Therapy—Speech Generating Device (CPT code 92609)Speech therapists provide therapeutic services for the use of speech-generating device. When the patient hasthe device, the therapists may work on appropriate use of the device for communication, on how to use thedevice or programming or modifying the device for the patient. The patient should be present during thesesessions (Ogden, et al., 2017).Auditory/Aural Rehabilitation—Following Cochlear or Auditory Brainstem Implantation (CPT codes:92626, 92627, 92630, 92633)Aural rehabilitation refers to services and procedures for facilitating adequate receptive and expressivecommunication in individuals with hearing impairments, and is also be referred to as auditory or audiologicrehabilitation. Aural rehabilitation following implantation cochlear device and auditory brainstem implantation ofthese devices is considered an integral part of the overall management of implant patients. Programs may varywidely, both with regard to treating disciplines and to the duration and scope of treatment, the general consensusPage 5 of 25Medical Coverage Policy: 0177
is that some type of post-implantation aural therapy maximizes the benefit of the device. Sound recognition andspeech intelligibility are evaluated prior to and just after implantation. Hearing capabilities are assessed by anaudiologist, both with and without the assistance of a hearing aid. A speech-language pathologist evaluates andcategorizes the patient's pre-implantation speech and language skills. Post-cochlear implantation rehabilitationprograms generally include the following components: sound awareness (e.g., recognition of novel auditorysignals); visual/auditory processing, including speech-reading training (e.g., lip-reading, facial expression,gestures and body language); speech recognition; mechanical (e.g., use of the device and telephone); andvoice, speech production and language therapy.PresbycusisPresbycusis is the general term applied to age-related hearing loss and is used to describe the sum of all theprocesses that affect hearing over time. Presbycusis affects both of the critical dimensions of hearing byreducing threshold sensitivity as well as the ability to understand speech. Individuals with presbycusis often donot express difficulty hearing, but are more likely to complain of problems understanding speech. Hearing aidsare the primary resource for improving communication and reducing hearing handicaps in those withsensorineural presbycusis. Although communication strategies are employed in the management of presbycusis,a comprehensive, structured aural rehabilitation program is typically not used as a treatment modality for adultonset hearing loss that is associated with the aging process.Speech and Language ImpairmentsLanguage impairment is the inability to comprehend and/or appropriately use language. The impairment mayinvolve the form of language (i.e., phonology, morphology, and syntax), the content of language (i.e., semantics),the function of language in communication (i.e., pragmatics), or any combination of the above. The termslanguage or speech impairment do not include dialectal differences, auditory processing disorders or selectivemutism. Language is the brain's use of symbols for communication. Language is the unique human ability tocommunicate through symbols, whether spoken or written language, Braille, musical notation, or most forms ofsign language. Language is distinct from speech, which is the verbal expression of language.Speech and language impairments can result from a variety of local, systemic and neurological conditions.Examples of local impairments are injury or localized disease of the vocal cords; tumors or growths that c
Speech therapy is the treatment of defects and disorders of speech and language disorders. Prior to the initiation of speech therapy, a comprehensive evaluation of the patient and his or her speech and language potential is generally required before a full treatment plan is formulated. As part of the evaluation, standardized assessment
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speech 1 Part 2 – Speech Therapy Speech Therapy Page updated: August 2020 This section contains information about speech therapy services and program coverage (California Code of Regulations [CCR], Title 22, Section 51309). For additional help, refer to the speech therapy billing example section in the appropriate Part 2 manual. Program Coverage
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