These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.
Prior authorization is required for more than 20 visits of habilitative speech therapy in a calendar year.
- Oral motor, feeding and swallowing problems are evaluated for coverage under the “Feeding/oral function therapy, pediatric” policy. Please see related content at right for link.
- Occupational Therapy (OT) visits count towards Physical Therapy (PT) limits unless modifier ‘GO’ is used when billing.
Habilitative speech therapy is available when it meets the definitions below and is subject to the following indications.
Habilitative therapy services are covered only when provided in a clinic, office or in an outpatient setting and ordered by either a primary care provider or specialist.
Indications that are covered
- Must have written orders from primary care or specialist provider. Autism diagnoses and treatment recommendations must be made by a psychiatrist, psychologist or developmental pediatrician who has training and expertise in autism spectrum disorder and child development.
- To be eligible for speech therapy services, evaluations must include age-appropriate standardization tests documenting a condition/developmental delay resulting in articulation abilities or impairment of the initiation of language skills (expressive or receptive language) that are at or below the 10th percentile or 1.5 or greater standard deviations below the mean for the member’s age.
When standardized testing that determines standard deviation or percentile ranking cannot be completed, age equivalency scores will be accepted to meet this criterion. As age equivalency scores are the least accurate statistical measurement, standard deviation scores or percentile rankings are preferred. To constitute the basis for coverage of habilitative speech therapy, the age equivalency testing must show at least a 25% delay based upon the age of the member in months.
- Speech therapy services for dysfluency (stuttering) are eligible for coverage when age-appropriate standardized tests demonstrate either:
- Stuttering Like Dysfluencies (SLD) greater than or equal to 10/100 (10%); or
- Secondary physical manifestations such as clenching jaw, blinking, expelling breath; or
- Stuttering Severity Index (SSI) of Moderate.
- Treatment goals should promote achievement of developmental milestones appropriate to the member’s age and condition.
- Evaluations are required at least annually for ongoing treatment and should contain specific documentation regarding progress towards goals. Periodic re-evaluations are required to document measurable functional progress toward treatment goals and the continued need for therapy.
- For continued habilitative therapy coverage, members must continue to demonstrate a significant delay (e.g., 1.5 standard deviations), and must demonstrate measurable functional improvement.
- A discharge plan, with proposed treatment duration, must be submitted that demonstrates plans to wean services once the above criteria are no longer met.
- For members no longer meeting coverage criteria, a weaning process of three to six months will occur. If regression in function occurs, services will be re-evaluated for coverage.
Indications that are not covered
- Group therapy, except when used in the context of a child diagnosed with autism.
- Educational therapy.
- Therapy when measurable functional improvement is not expected or progress has plateaued.
- Accent/dialect reduction.
- Therapy to improve attention, memory, problem solving, organizational skills and time management.
- Therapy to improve speech for a second language.
Apraxia of speech refers to impairment in the ability to program the speech musculature to select, plan, organize, and initiate a motor pattern.
Central Auditory Processing Disorder refers to difficulty processing and remembering a variety of language related tasks.
Dysfluency is impairment of the ability to produce smooth, fluent speech.
Early Intervention Program is a government-subsidized public program designed to serve children with special needs and/or developmental delays from the time the problem is identified until the third birthday. Among other professionals, assessment teams will almost always include speech-language pathologists (SLPs) and occupational therapists who can develop appropriate intervention plans without a categorical diagnosis.
Educational therapy refers to skills that are typically taught in a school or educational setting.
Expressive language refers to the ability to produce or use language.
Functional skills are defined as essential activities of daily life common to all members such as communication. Measurable progress emphasizes mastery of functional skills and independence in the context of the member's potential ability as specified within a care plan or treatment goals.
Gestural communication refers to the ability to communicate nonverbally (e.g., by pointing, nodding or shaking the head, using and interpreting facial expressions, and using and coordinating eye contact).
Habilitative speech therapy is care rendered for conditions which have significantly limited the successful initiation of normal speech development. To be considered habilitative, measurable functional improvement and measurable progress must be made toward achieving functional goals, within a predictable period of time toward a member's maximum potential.
Measurable functional improvement for habilitative therapy will be assessed by comparison of the progress towards goals as documented in current progress reports. The determination of whether measurable progress is being made is at the sole discretion of the medical director and his or her designee and is made on a case by case basis. In cases where progress is questioned, the medical director and his or her designee will consult with the treating therapist, and/or a speech therapist consultant when making the coverage determination.
Phonological disorder refers to a type of speech articulation disorder including not using speech sounds expected for age group, or patterns of error of sound use.
Receptive language refers to the ability to understand language.
Speech refers to the ability to produce vocal sounds.
The services associated with these codes require prior authorization:
Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals
The services associated with these codes DO NOT require prior authorization:
Evaluation of speech fluency (e.g., stuttering, cluttering)
Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria);
Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language)
Behavioral and qualitative analysis of voice and resonance
CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.
- American SpeechLanguageHearing Association. (1993). Definitions of communication disorders and variations [Relevant Paper.] Available from www.asha.org/policy.
- American SpeechLanguageHearing Association. (2005a). Roles and responsibilities of speech-language pathologists serving persons with mental retardation/developmental disabilities [Guidelines]. Available from www.asha.org/policy.
- American SpeechLanguageHearing Association. (2005b). Roles of speechlanguage pathologists in the identification, diagnosis, and treatment of individuals with cognitive-communication disorders: position statement [Position Statement]. Available from www.asha.org/policy.
- American SpeechLanguageHearing Association. (2007). Childhood apraxia of speech [Position Statement]. Available from www.asha.org/policy.
- Carter, J., & Musher, K. Evaluation and treatment of speech and language disorders in children. In: UpToDate, Duryea, T. K., Augustyn, M., & Torchia, M. M. (Eds.), UpToDate, Waltham, MA. (Accessed on November 16, 2016.)
- Carter, J., & Musher, K. Etiology of speech and language disorders in children. In: UpToDate, Augustyn, M., & Torchia, M. M. (Eds.), UpToDate, Waltham, MA. (Accessed on November 16, 2016.)
- Dobie, C., Donald, W. B., Hanson, M., Heim, C., Huxsahl, J., Karasov, R., … Steiner, L. Institute for Clinical Systems Improvement. (2012). Health care guideline: Diagnosis and management of attention deficit hyperactivity disorder in primary care for school-age children and adolescents (9th ed.). Retrieved from https://www.icsi.org/guidelines__more/
- Gibson, J., Adams, C., Lockton, E., & Green, J. (2013). Social communication disorder outside autism? A diagnostic classification approach to delineating pragmatic language impairment, high functioning autism and specific language impairment. Journal of Child Psychology and Psychiatry, (54)11, 1186-197. doi:10.1111/jcpp.12079.
- Hayes, Inc. Hayes Medical Technology Directory Report. Social skills training for autistic spectrum disorders. Lansdale, PA: Hayes, Inc.; October, 2011. Reviewed October, 2015.
- Johnson, C. P., Myers, S. M., & the Council on Children with Disabilities. (2007). Identification and evaluation of children with autism spectrum disorders. PEDIATRICS, (120)5, 1183-1216. doi:10.1542/peds.2007-2361.
- Sices, L. Overview of expressive language delay ("late talking") in young children. In: UpToDate, Augustyn, M., & Torchia, M. M. (Eds.), UpToDate, Waltham, MA. (Accessed on November 16, 2016.)
- Simms, M. D., & Jin, X. M. (2015). Autism, language disorder, and social (pragmatic) communication disorder: DSM-V and differential diagnoses. Pediatrics in Review, (36)8 (2015): 355-64. doi: 10.1542/pir.36-8-355
- Swineford, L. B., Thurm, A., Baird, G., Wetherby, A. M., & Swedo, S. (2014). Social (pragmatic) communication disorder: a research review of this new DSM-5 diagnostic category. Journal of Neurodevelopmental Disorders, (6)41. doi: 10.1186/1866-1955-6-41