Subject: Speech Therapy
Date: June 5, 2012
This Clinical Policy Bulletin expresses our determination of whether certain services or supplies are medically necessary. We have reached these conclusions based on a review of currently available clinical information including:
- Clinical outcome studies in the peer-reviewed published medical and dental literature
- Regulatory status of the technology
- Evidence-based guidelines of public health and health research agencies
- Evidence-based guidelines and positions of leading national health professional organizations
- Views of physicians and dentists practicing in relevant clinical areas
- Other relevant factors
We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.
Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to consult the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members
Commercial HMO-based (HMO, QPOS) plans:
Note: Most Aetna HMO-based plans provide coverage for short-term speech therapy for non-chronic conditions and acute illnesses and injuries, subject to applicable terms and limitations. Services rendered for the treatment of delays in speech development (unless resulting from disease, injury or congenital defects) are commonly excluded. Please check benefits plan descriptions for details. Under these plans, speech therapy is covered for the following indications:
- To restore or improve speech in members who have speech-language disorders that are the result of a non-chronic disease or acute injury
- The member has a speech delay that is associated with a specifically diagnosable disease, injury,or congenital defect (for example, cleft palate, cleft lip, etc.).
Precertification of speech therapy may be required in certain plan designs. Speech therapy also may be a limited benefit. Often, in Aetna commercial HMO-based plans, the benefit is limited to a 60-day treatment period. The treatment period of 60 days applies to a specific condition. Once the 60-day treatment period ends, no additional speech therapy benefits will be provided for that condition.
However, it is possible for a member to receive more than one 60-day treatment course of speech therapy when the need is the result of a separate condition. For example, a stroke or a surgical procedure causing the need for speech therapy is considered to be the start of a new or separate condition in a person who previously received this service for another reason, and so qualifies the member to receive coverage for an additional course of speech therapy as outlined above. An exacerbation or flare-up of a chronic illness is not considered a new incident of illness.
Traditional (Indemnity, PPO and Managed Choice) Plans:
Note: Aetna's traditional (indemnity, PPO and Managed Choice) plans usually limit coverage of speech therapy to treatment to restore speech to a person who has lost existing speech function (the ability to express thoughts, speak words and form sentences) as a result of disease or injury. Please check benefits plan descriptions for details. Speech therapy for the treatment of delays in speech development (unless resulting from disease, injury or congenital defect) is not covered under most traditional plans.*
Note: Coverage for speech therapy benefits under traditional plans range from a defined number of visits per year to unlimited benefits. Benefit levels are determined by the particular benefits plan selected by the employer or contract holder. Please check benefits plan descriptions for details.
See also CPB 625 - Dysphagia Therapy, http://www.aetna.com/cpb/medical/data/600_699/0625.html
Non-Medically Necessary Indications:
Speech therapy is considered not medically necessary in the following
Non-covered indications for speech therapy for children:
- Duplicate therapy when members receive both occupational and speech therapy. The therapies should provide different treatments and not duplicate the same treatment..
- Treatments are not considered medically necessary if they do not require the skills of a qualified provider of speech therapy services, such as treatments that maintain function by using routine, repetitious, and reinforced procedures that are neither diagnostic nor therapeutic (for example, practicing word drills for developmental articulation errors) or procedures that may be carried out effectively by the patient, family, or caregivers at home on their own.
- Maintenance programs such as drills, techniques, and exercises that preserve the patient's present level of function and prevent regression of that function do not meet Aetna's contractual definition of medical necessity. 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.
- Speech therapy is considered not medically necessary for dysfunctions that are self-correcting, such as language therapy for young children with natural dysfluency or developmental articulation errors that are self-correcting.
- Note: Under plans that exclude coverage of speech therapy for delays in speech development, speech therapy for verbal apraxia or stuttering/stammering is not covered unless due to a specific disease or brain injury. Speech therapy is also not covered for the following conditions that are frequently encountered in school settings and in developmental learning centers:
- Psychosocial speech delay
- Behavioral problems
- Attention disorders
- Conceptual handicap
- Mental retardation.
Most Aetna plans exclude coverage of educational interventions. Under these plans, speech therapy that is primarily educational in nature (such as in treatment of pervasive developmental disorders and mental retardation) is excluded from coverage. Please check benefit plan descriptions.
For clinical policy on speech therapy for persons with a diagnosis
of autistic spectrum disorder, see CPB 648 - Pervasive Developmental Disorders, http://www.aetna.com/cpb/medical/data/600_699/0648.html
Some HMO and traditional plans cover speech therapy for idiopathic delays in speech development. Under these plans, speech therapy is considered medically necessary for idiopathic delays in speech development when both of the following criteria are met:
- The member is 18 months of age or older; and
- The member has been evaluated by a qualified speech-language therapist who has determined that he or she has a treatable communication problem.
Speech therapy for idiopathic delays in speech development is considered experimental and investigational for infants and children younger than 18 months of age because idiopathic delays in speech development cannot be reliably diagnosed or treated in the prelingual developmental stage.
Home-based speech therapy:
Aetna considers home-based speech therapy medically necessary in selected cases based upon the member's needs. This is usually used in the transition of the member from hospital to home and is an extension of case management services.
In Aetna HMO and QPOS plans, such short-term speech therapy accumulates toward the 60-day limit or other applicable rehabilitation benefit limits. Please check benefits plan descriptions for details.
Facilitated communication is considered experimental and investigational for
all indications. See CPB 648 - Pervasive Developmental Disorders, http://www.aetna.com/cpb/medical/data/600_699/0648.html.
Altered auditory feedback devices:
Altered auditory feedback devices are considered experimental and investigational for stuttering and all other indications because of a lack of evidence in the peer-reviewed published medical literature on the effectiveness of these devices.
In addition, altered auditory feedback devices are communication aids that are not considered prosthetics for speech because they are not speech generating devices. Thus, altered auditory feedback devices would be excluded from coverage under plans that exclude coverage of communication aids. Please check benefits plan descriptions. Brands of altered auditory feedback devices include the SpeechEasy®
(Janus Development Group, Greenville, NC), the Fluency Master (National Medical Equipment, Inc., New Hyde Park, NY), and the Fluency Enhancer (Casa Futura Technologies, Boulder, CO).
Augmentive and alternative communication devices:
For criteria for augmentive and alternative communication devices, see CPB 437 - Speech Generating Devices,
There is inadequate evidence of the effectiveness of facilitated communication. The American Psychological Association (2004) has determined that “facilitated communication is a controversial and unproved communicative procedure with no scientifically demonstrated support for its efficacy.” Other national professional organizations adopting formal positions opposing facilitated communication as a valid mode of enhancing expression for people with disabilities include the American Academy of Pediatrics, the American Association on Mental Retardation, the American Academy of Child & Adolescent Psychiatry and the American Speech-Language-Hearing Association.
Altered auditory feedback devices
The SpeechEasy Anti-Stuttering Device uses delayed auditory feedback and frequency altered feedback to create the illusion of another person speaking in unison with the user. By emulating this 'choral speech' pattern, the SpeechEasy device is intended to increase fluency of persons who stutter. The Fluency Enhancer Anti-Stuttering Device also uses digital delayed auditory feedback and frequency altered feedback that is designed for temporary use in a protocol developed by the National Center for Stuttering. However, there is a lack of evidence in the peer-reviewed published medical literature on the effectiveness of the SpeechEasy or Fluency Enhancer anti-stuttering devices. Ingham and Ingham (2003) commented that “[t]here is not a single peer-reviewed, published clinical research study demonstrating that this device produces sustained and satisfactory improvements in fluency - and for what percentage and age range of people who stutter - let alone that it produces benefits that are retained following extended use.”
The Fluency Master Anti-Stuttering Device is a miniature, wearable, electronic stuttering- control device that looks like a hearing aid. The Fluency Master works on an auditory feedback principle. The Fluency Master modifies vocal tone with the help of a miniature microphone positioned near the user's mastoid area. The microphone picks up vibrations conducted through bone from the user's larynx. The Fluency Master then amplifies this “bone conduction” vibration, so the user hears his voice differently than he normally does. There is a lack of clinical evidence in the peer-reviewed published medical literature on the effectiveness and durability of results of the Fluency Master in persons who stutter.
Altered auditory feedback devices are also being investigated for use in treatment of rate and rhythm dysarthria associated with Parkinson disease, transient spasmodic dysphonia, and laryngeal spasms. However, there is a lack of scientific evidence to support the effectiveness of altered auditory feedback devices for these indications.
Speech therapy should be provided in accordance with an ongoing, written plan of care. The purpose of the written plan of care is to assist in determining medical necessity. The following care plan documentation is required to justify the medical necessity of speech therapy:
- The plan of care should include sufficient information to determine the medical necessity of treatment. The plan of care should be specific to the diagnosis, presenting symptoms, and findings of the speech therapy evaluation.
- The plan of care must be signed by the member's attending physician and speech therapist.
- The plan of care should include:
- The date of onset or exacerbation of the disorder/diagnosis
- Specific statements of long-term and short-term goals
- Quantitative objectives measuring current age-adjusted level of functioning
- A reasonable estimate of when the goals will be reached
- The specific treatment techniques and/or exercises to be used in treatment
- The frequency and duration of treatment.
- The plan of care should be ongoing (that is, updated as the member's condition changes) and treatment should demonstrate reasonable expectation of improvement (as defined below):
- Speech therapy services are considered medically necessary only if there is a reasonable expectation that speech therapy will achieve measurable improvement in the member's condition in a reasonable and predictable period of time.
- The member should be reevaluated regularly, and there should be documentation of progress made toward the goals of speech therapy.
- The treatment goals and subsequent documentation of treatment results should specifically demonstrate that speech therapy services are contributing to such improvement.
|Speech Therapy other than with cochlear implants or hearing aids:
|CPT codes covered if selection criteria are met:
||Treatment of speech, language, voice, communication and/or auditory processing disorder; individual
||group, two or more individuals
|Other CPT codes related to the CPB:
||Occupational therapy evaluation
||Occupational therapy reevaluation
||Self-care/home management training (for example, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes
|Other HCPCS codes related to the CPB:
||Occupational therapy services requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per session (45 minutes or more)
||Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes
||Services performed by a qualified speech and language pathologist in the home health or hospice setting, each 15 minutes
||Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective therapy maintenance program, each 15 minutes
||Speech therapy, in the home, per diem
||Occupational therapy, in the home, per diem
|ICD-9 codes covered if selection criteria are met:
|141.0 - 141.9 ||Malignant neoplasm of tongue |
|142.0 - 142.9 ||Malignant neoplasm of salivary glands |
|1430. - 143.9 ||Malignant neoplasm of gum |
|144.0 - 144.9 ||Malignant neoplasm of floor of mouth|
|145.0 - 145.9 ||Malignant neoplasm of other and unspecified parts of the mouth|
|146.0 - 146.9 ||Malignant neoplasm of oropharynx |
|147.0 - 147.9 ||Malignant neoplasm of nasopharynx |
|148.0 - 148.9 ||Malignant neoplasm of hypopharynx |
|149.0 - 149.9 ||Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx |
|161.0 - 161.9
||Malignant neoplasm of larynx
||Benign neoplasm of larynx
||Carcinoma in situ of larynx
|430 - 437.9
|438.10 - 438.19
||Late effects of cerebrovascular disease, speech and language deficits
|438.20 - 438.22
||Late effects of cerebrovascular disease, hemiplegia/hemiparesis
||Late effects of cerebrovascular disease, apraxia
||Other anomalies of larynx, trachea, and bronchus
|749.00 - 749.25
||Cleft palate and cleft lip
|800.00 - 804.99
||Fracture of skull
|850.00 - 854.19
|874.00 - 874.12
||Open wound of larynx with trachea
||Late effect of fracture of skull and face bones
||Late effect of open wound of head, neck, and trunk
||Late effect of intracranial injury without mention of skull fracture
||Late effect of injury to cranial nerve
||Personal history of malignant neoplasm of tongue
|V10.02 ||Personal history of malignant neoplasm of other and unspecified oral cavity and pharynx|
|V10.21 ||Personal history of malignant neoplasm of larynx|
||Organ or tissue replaced by other means, larynx
|ICD-9 codes not covered for indications listed in the CPB (not all inclusive):
||Other and unspecified special symptoms or syndromes, not elsewhere classified
||Adjustment reaction with withdrawal
|314.00 - 314.01
||Attention deficit disorder without mention of hyperactivity or with hyperactivity
|317 - 319
||Lack of coordination
|784.52||Fluency disorder in conditions classified elsewhere |
||Alexia and dyslexia
||Other symbolic dysfunction
|V40.0 - V40.9
||Mental and behavioral problems
|V41.2 - V41.4
||Problems with hearing, other ear problems, and problems with voice production
|Other ICD-9 codes related to the CPB:
|299.00 - 299.91
||Pervasive developmental disorders
|315.00 - 315.9
||Specific delays in development
||Care involving use of rehabilitation procedures, speech therapy [additional code required for underlying condition]
||Encounter for occupational therapy [when both occupational and speech therapy provided, different treatments required - not duplicate of same]
|Speech therapy with cochlear implants and hearing aids:
||Auditory rehabilitation; pre-lingual hearing loss
||post-lingual hearing loss
|There are no specific codes for facilitated communication
|Altered auditory feedback devices:
|There are no specific codes for altered auditory feedback devices
|ICD-9 codes not covered for indications listed in the CPB:
||Other diseases of larynx
||Other speech disturbance
The above policy is based on the following references:
- Agency for Healthcare Policy and Research (AHCPR). Post-stroke rehabilitation. AHCPR Clinical Practice Guideline No. 16. AHCPR Publication No. 95-0062. Rockville, MD: AHCPR; May 1995.
- MacKenzie EH, Freedman DJ. A paradigm for improving effectiveness and efficiency of speech- language therapy. Int J Lang Commun Disord. 1998;33 Suppl:544-549.
- Lucas C, Rodgers H. Variation in the management of dysphagia after stroke: does SLT make a difference? Int J Lang Commun Disord. 1998;33 Suppl:284-289.
- Petheram B. A survey of speech and language therapists' practice in the assessment of aphasia. Int J Lang Commun Disord. 1998;33 Suppl:180-182.
- Greener J, Grant A. Beliefs about effectiveness of treatment for aphasia after stroke. Int J Lang Commun Disord. 1998;33 Suppl:162-163.
- Greener J, Enderby P, Whurr R, Grant A. Treatment for aphasia following stroke: evidence for effectiveness. Int J Lang Commun Disord. 1998;33 Suppl:158-161.
- Enderby P, Petheram B. Changes in referral to speech and language therapy. Int J Lang Commun Disord. 1998;33 Suppl:16-20.
- Furlong M. Speech therapy. Nurs Stand. 1999;13(22):16.
- ECRI Evidence-Based Practice Center. Diagnosis and treatment of swallowing disorders (dysphagia) in acute-care stroke patients. Evidence Report/Technology Assessment No. 8. Prepared for the Agency for Health Care Policy and Research (AHCPR), Contract No. 290-97-E020. AHCPR Publication No. 99-E024. Rockville, MD: AHCPR; July 1999.
- Hillman RE, Walsh MJ, Wolf GT, et al. Functional outcomes following treatment for advanced laryngeal cancer. Part I--Voice preservation in advanced laryngeal cancer. Part II-- Laryngectomy rehabilitation: the state of the art in the VA System. Research Speech-Language Pathologists. Department of Veterans Affairs Laryngeal Cancer Study Group. Ann Otol Rhinol Laryngol Suppl. 1998;172:1-27.
- Chesnut RM, Carney N, Maynard H, et al. and the Oregon Health Sciences University Evidence-Based Practice Center. Rehabilitation for traumatic brain injury. Evidence Report/Technology Assessment Number 2. Prepared for the Agency for Health Care Policy and Research (AHCPR), Contract No. 290-97-0018. AHCPR Publication No. 99-E006. Rockville, MD: AHCPR; February 1999.
- Carney N, du Coudray H, Davis-O'Reilly C, et al., and the Oregon Health Sciences University Evidence-Based Practice Center. Rehabilitation for traumatic brain injury in children and adolescents. Evidence Report/Technology Assessment No. 2, Supplement. Prepared for the Agency for Health Care Policy and Research (AHCPR), Contract No. 290-97-0018. AHCPR Publication No. 00-E001. Rockville, MD: AHCPR; September 1999.
- Glogowska M, Campbell R. Investigating parental views of involvement in pre-school speech and language therapy. Int J Lang Commun Disord. 2000;35(3):391-405.
- John A, Enderby P. Reliability of speech and language therapists using therapy outcome measures. Int J Lang Commun Disord. 2000;35(2):287-302.
- Costa D, Kroll R. Stuttering: an update for physicians. CMAJ. 2000;162(13):1849-1855.
- Enderby PM, John A. Therapy outcome measures in speech and language therapy: comparing performance between different providers. Int J Lang Commun Disord. 1999;34(4):417-429.
- Burke D, Alexander K, Baxter M, et al. Rehabilitation of a person with severe traumatic brain injury. Brain Inj. 2000;14(5):463-471.
- Peters HF, Hulstijn W, Van Lieshout PH. Recent developments in speech motor research into stuttering. Folia Phoniatr Logop. 2000;52(1-3):103-119.
- Sellars C, Hughes T, Langhorne P. Speech and language therapy for dysarthria due to non-progressive brain damage. Cochrane Database Syst Rev. 2005;(3):CD002088.
- Deane KHO, Whurr R, Clarke CE, et al. Non-pharmacological therapies for dysphagia in Parkinson's disease. Cochrane Database Syst Rev. 2001;(1):CD002816.
- Deane KHO, Whurr R, Playford ED, et al. Speech and language therapy for dysarthria in Parkinson's disease: A comparison of techniques. Cochrane Database Syst Rev. 2001;(2):CD002814.
- Greener J, Enderby P, Whurr R. Speech and language therapy for aphasia following stroke. Cochrane Database Syst Rev. 1999;(4):CD000425.
- Law J, Garrett Z, Nye C. Speech and language therapy interventions for children with primary speech and language delay or disorder. Cochrane Database Syst Rev. 2003;(3):CD004110.
- Pennington L, Goldbart J, Marshall J. Speech and language therapy to improve the communication skills of children with cerebral palsy. Cochrane Database Syst Rev. 2003;(3):CD003466.
- Clarke C, Moore AP. Parkinson's disease. In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; November 2006.
- American Speech-Language Hearing Association (ASHA). Getting health plans to pay for pediatric verbal apraxia. ASHA Leader Online. Rockville, MD: ASHA; November 5, 2002.
- Prelock P. Understanding autism spectrum disorders: The role of speech-language pathologists and audiologists in service delivery. ASHA Leader Online. Rockville, MD: American Speech-Language-Hearing Association (ASHA); 2001.
- National Institutes of Health (NIH), National Institute on Deafness and Other Communication Disorders (NIDOCD). Stuttering. NIH Pub. No. 97-4232. Bethesda, MD: NIH; updated May 2002.
- American Speech-Language-Hearing Association (AHSA). Stuttering. Speech and Language Disorders. Rockville, MD: ASHA; 2002.
- Janus Development Group, Inc. SpeechEasy. Let's Talk
[website]. Greenville, NC: Janus Development Group; 2004. Available at: http://www.speecheasy.com/.
Accessed August 6, 2004.
- Ingham RJ, Ingham JM. No evidence-based data on SpeechEasy. Letters. The ASHA Leader Online. Rockville, MD: American Speech-Language-Hearing Association (ASHA); April 15, 2003.
- National Association for Speech Fluency. Fluency Master.
Stuttering Control Home Page [website]. New Hyde Park, NY: National Medical
Equipment, Inc.; September 18, 2000. Available at: http://www.stutteringcontrol.com/.
Accessed August 6, 2004.
- Zimmerman S, Kalinowski J, Stuart A, Rastatter M. Effect of altered auditory feedback on people who stutter during scripted telephone conversations. J Speech Lang Hear Res. 1997;40(5):1130-1134.
- Natke U, Kalveram KT. Effects of frequency-shifted auditory feedback on fundamental frequency of long stressed and unstressed syllables.. J Speech Lang Hear Res. 2001;44(3):577-584.
- Natke U, Glosser J, Kalveram KT. Fluency, fundamental frequency, and speech rate under frequency-shifted auditory feedback in stuttering and nonstuttering persons. J Fluency Disord. 2001;26(3):227-241.
- Bilney B, Morris ME, Perry A. Effectiveness of physiotherapy, occupational therapy, and speech pathology for people with Huntington's disease: A systematic review. Neurorehabil Neural Repair. 2003;17(1):12-24
- Stuart A, Kalinowski J, Rastatter M, et al. Investigations on the impact of altered auditory feedback in-the-ear devices on the speech of people who stutter: Initial fitting and 4-month follow-up. J Language Commun Disord. 2004;39(1):93-113.
- Lowit A, Brendel E. The response of patients with Parkinson's disease to DAF and FSF. Stammering Res. 2004;1:58-61.
- Pinto S, Ozsancak C, Tripoliti E, et al. Treatments for dysarthria in Parkinson's disease. Lancet Neurol. 2004;3(9):547-556.
- Stark C, Lees R, Black C, Waugh N. Altered auditory feedback treatments for stuttering in childhood and adolescence (Protocol for Cochrane Review). Cochrane Database Syst Rev. 2004;(1):CD004859.
- National Center for Stuttering (NCS). The NCS Fluency
Enhancer [website]. New York, NY: NCS; 2005. Available at: http://www.stuttering.com.
Accessed April 8, 2005.
- Casa Future Technologies. The Fluency Enhancer [website].
Boulder, CO: Casa Futura Technologies; 2005. Available at: http://www.fluencyenhancer.com/.
Accessed April 8, 2005.
- American Psychological Association. VI. Facilitated communication. Council Policy Manual: M. Scientific Affairs. Washington, DC: American Psychological Association; August 1994.
- American Academy of Child and Adolescent Psychiatry (AACAP). Facilitated communication, Policy Statements. Washington, DC: AACAP; approved October 20, 1993.
- American Academy of Pediatrics (AAP), Committee on Children with Disabilities. Auditory integration training and facilitated communication for autism. Pediatrics. 1998;102(2):431-433. Available at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;102/2/431. Accessed July 31 , 2006.
- American Speech-Language-Hearing Association (ASHA). Position statement: Facilitated communication. ASHA.1995;37(14 Suppl.):22.
- Nelson HD, Nygren P, Walker M, Panoscha R. Screening for speech and language delay in preschool children. Evidence Synthesis No. 41. Rockville, MD: Agency for Healthcare Quality and Research (AHRQ); 2006.
- Cuerva Carvajal A, Marquez Calderon S, Sarmiento Gonzulez-Nieto V. Outcomes of treatments for stuttering. Executive Summary. Informe 5/2007. Sevilla, Spain: Andalusian Agency for Health Technology Assessment (AETSA); 2007.
Original policy: November 4, 2004
Updated: January 20, 2011; June 5, 2012
Revised: September 25, 2006; August 26, 2008; November 16, 2009
Medical Bulletin #0243
: : May 1, 2012
This CPB has been updated with additional background information and references.