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 benefit plan descriptions for details. Under these plans, speech therapy is covered for the following indications:

1. To restore or improve speech in members who have speech-language disorders that are the result of a non-chronic disease or acute injury; or
2. The member has a speech delay that is associated with a specifically diagnosable disease, injury, or congenital defect (e.g., cleft palate, cleft lip, etc.).

Note: 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 expires, 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 initiation 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 that which is expected 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 benefit 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 benefit plan selected by the employer or contract holder. Please check benefit plan descriptions for details.

See also CPB 625 - Dysphagia Therapy.

Non-Medically Necessary Indications:

Speech therapy is considered not medically necessary in the following circumstances:

1. Duplicate therapy when members receive both occupational and speech therapy; the therapies should provide different treatments and not duplicate the same treatment.
2. Treatments are not considered medically necessary if they do not require the skills of a qualified provider of speech therapy services, such as treatments which maintain function by using routine, repetitious, and reinforced procedures that are neither diagnostic nor therapeutic (e.g., 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.
3. 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.

Non-covered indications for speech therapy for children:

1. 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.
2. 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:
   1. Psychosocial speech delay
   2. Behavioral problems
   3. Attention disorders
   4. Conceptual handicap
   5. Mental retardation.

3. Note: 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.

Note: For clinical policy on speech therapy for persons with a diagnosis of autistic spectrum disorder, see CPB 648 - Pervasive Developmental Disorders.

*Note: Some HMO and traditional plans do not exclude coverage of 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:

1. The member is 18 months of age or older; and
2. The member has been evaluated by a qualified speech-language therapist who has determined that a treatable communication problem exists.

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. Note: In Aetna HMO and QPOS plans, such short-term speech therapy accumulates towards the 60-day limit or other applicable rehabilitation benefit limits. Please check benefit plan descriptions for details.

Facilitated Communication:

Facilitated communication is considered experimental and investigational for all indications. See CPB 648 - Pervasive Developmental Disorders.

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. Note: 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 benefit 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,  seeCPB 437 - Speech Generating Devices.

Facilitated Communication

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.

Appendix

Documentation Requirements:

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:

1. 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.
2. The plan of care must be signed by the member's attending physician and speech therapist.

3. The plan of care should include:

   1. The date of onset or exacerbation of the disorder/diagnosis;
   2. Specific statements of long-term and short-term goals;
   3. Quantitative objectives measuring current age-adjusted level of functioning;
   4. A reasonable estimate of when the goals will be reached;
   5. The specific treatment techniques and/or exercises to be used in treatment; and

   6. The frequency and duration of treatment.

4. The plan of care should be ongoing (i.e., updated as the member's condition changes) and treatment should demonstrate reasonable expectation of improvement (as defined below):

   1. 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.
   2. The member should be reevaluated regularly, and there should be documentation of progress made toward the goals of speech therapy.
   3. The treatment goals and subsequent documentation of treatment results should specifically demonstrate that speech therapy services are contributing to such improvement.