Speech Therapy Criteria
Reviewed: 2/07, 2/08, 1/13, 3/14, 2/15, 1/16, 1/17
Revised: 1/09, 3/10, 2/11, 1/12
Speech therapy provides remediation or rehabilitation for speech and language impairments.
Speech therapy is covered when one of the following criteria is met:
- A medically determined, severe functional impairment of swallowing, cognition or speech exists, as measured by age-appropriate standardized tests that determine the extent of the impairment, performance deviation, language, and pragmatic skills assessment levels. The impairment results from disease, trauma, an underlying structural malformation, or previous therapeutic processes. This would include impairment such as dysphasia, aphasia and neglect from cerebral vascular accidents and traumatic brain injury. Coverage is provided for evaluation, testing and treatment of cognitive disorders after traumatic brain injury.
- In children with speech delay, there is documented evidence of previous injury, congenital structural malformation or disease that is impacting speech.
- A child of four years of age or less with speech delay and a documented history of otitis media who has one of the following:
- Recurrent acute otitis media identified as at least four episodes in the past six months, with a documented hearing loss of greater than or equal to 20 decibels
- Chronic otitis media for eight weeks or longer and a history of tympanostomy-tube placement
Speech therapy is covered when all of the following criteria are met:
- An evaluation has been completed by a certified speech language pathologist and the treatment has been ordered.
- The speech therapy ordered requires one-to-one intervention and supervision by a speech language pathologist.
- The speech therapy plan includes specific tests and measures that will be used to document significant progress every two weeks.
- The therapeutic services continue to meet medical necessity criteria, and the enrollee has not plateaued with no additional meaningful improvement measured or expected.
- The treatment includes a transition from one-on-one supervision to a patient maintenance or caregiver level upon discharge.
Speech therapy is not covered for the following conditions without evidence of an underlying medical condition:
- Myofunctional therapy for dysfluency, such as stuttering, spastic dysphonia or other involuntarily acted conditions.
- Functional articulation disordered such as tongue thrust, lisp, or verbal apraxia.
- Pervasive developmental disorders, mental retardation, autism, or attention deficits.
- Idiopathic, slow speech-language delay.