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 (ST) 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.
When a request for habilitative speech therapy has been determined not to be not medically necessary, the member will not be eligible for further visits in the current or following calendar year unless further clinical evidence that supports medical necessity is submitted and services are determined to qualify for coverage.
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 outpatient setting and ordered by either a primary care provider or specialist.
For services that are only covered in the context of a child diagnosed with autism, the member’s autism diagnosis 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.
Many plans have benefit limitations that affect therapy coverage. These may include limiting therapy to a maximum allowable number of visits per calendar or plan year. When a limitation is present and the maximum allowable benefit is exhausted, services will no longer be covered even if the medical necessity criteria described below are met. Please see your plan documents for your specific coverage information.
Indications that are covered
- Requests for the initial habilitative ST authorization must include a clinical evaluation with results of current age-appropriate standardized testing. To qualify for coverage, scores must be:
- At or below the 10th percentile or 1.5 standard deviations or greater below the norm for the member’s age in articulation or language skills (expressive or receptive). If testing resulting in standard deviation or percentile ranking cannot be completed due to the member’s condition, a clinical evaluation including age equivalency scores that show at least a 25% delay based upon the age of the member in months will be accepted to meet this criterion. Or
- For dysfluency (stuttering), member must display 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.
- A treatment plan is required that documents
- diagnosis, type of treatment intervention to be performed, and anticipated frequency and duration of services, and
- long and short-term treatment goals with projected time frame for achievement, and
- clear criteria for discharge from therapy.
- Treatment goals and objectives must be specific, measurable, and promote achievement of milestones that are related to the member’s deficits/ areas of delay identified in the standardized testing.
- To be eligible for continued habilitative ST beyond the initial authorization:
- Members must continue to demonstrate a significant delay in functional skills as noted in criterion #1. New standardized testing may be requested if results of previous testing are incomplete or deemed to be outdated; and
- An updated treatment plan is required that documents
- measurable functional improvement towards goals
- the medical necessity for any change in frequency,
- a plan for transition to a home program and discharge.
- If all of the above criteria are met, habilitative ST services may be allowed for up to two times per week (up to 104 visits/year) for children through age five and, for those who are receiving therapy for the first time, during the initial year. For continued therapy for children over age five, therapy services may be allowed for up to 1 visit per week with an optional increase to 2 visits per week during the summer (up to 64 visits per year). Children with a diagnosis of autism or pervasive developmental disorder may qualify for increased services if medical necessity is demonstrated in the individual treatment plan.
Indications that are not covered
- Therapy is not covered in any of the following circumstances:
- Ongoing therapy is primarily custodial or maintenance in nature
- Therapy that does not require the skills of a licensed speech language pathologist (SLP)
- Member is unable to tolerate or participate in therapy due to a medical, psychological, or other condition; or
- Documentation indicates member is unable to participate in therapy goals; or
- Measurable progress is no longer being made to justify further therapy; or
- Member has met the treatment plan goals.
- Requests for additional visits within the current authorization period will not be approved unless the treatment plan provides documentation of a change in the member’s medical condition or functional status. Approved additional visits are subject to the limits outlined in #6 in the “Indications that are covered” section above.
- Group therapy, except when used in the context of a child diagnosed with autism
- Educational therapy (e.g., including but not limited to therapy for reading, spelling, or written language disorders)
- Accent/dialect reduction
- Therapy to improve attention, memory, problem solving, organizational skills and time management
- Therapy to improve speech for a second language
- Services that duplicate services that are provided as part of a member’s individual educational plan (IEP) or individual service plan (ISP)
- Habilitative therapy provided in the member’s home.
- Aquatic (pool) therapy for treatment of speech disorders in children is not covered as it is considered experimental/investigational. Reliable evidence does not permit conclusions concerning safety, effectiveness, or effect on health outcomes.
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 - essential activities of daily life (ADLS) 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.
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.
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 - care rendered by a licensed speech language pathologist 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.
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
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
Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring
Speech therapy, re-evaluation
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. (2005). Roles and responsibilities of speech-language pathologists serving persons with mental retardation/developmental disabilities [Guidelines]. 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 28, 2018.)
- 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 28, 2018.)
- 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/
- 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.
- McLaughlin, M. R. (2011). Speech and language delay in children. American Family Physician, 83(10), 1183-1188.
- Sices, L., & Augustyn, M. Expressive language delay ("late talking") in young children. In: UpToDate, Augustyn, M., & Torchia, M. M. (Eds.), UpToDate, Waltham, MA. (Accessed on November 28, 2018.)