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HealthPartners

Coverage criteria policies

Speech Therapy – Rehabilitative

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.

Administrative Process and Coverage

Under many HealthPartners plans, the number of speech therapy visits that can be received in one year is limited. Please refer to your plan documents for further information.

The following services are outside the scope of this policy:
  • Cognitive rehabilitation. Please see Related Content at right for link to the Cognitive Rehabilitation policy.
  • Feeding/ oral function therapy for members under age 18. Please see Related Content at right for link to the Feeding/ Oral Function Therapy – Pediatric policy.
  • Habilitative speech therapy. Please see Related Content at right for link to the Speech Therapy – Habilitative policy.
Prior authorization is required for the following services:
  • Speech therapy for non-covered indications (see below).
  • Speech therapy related to cleft lip/ cleft palate which extends beyond 2 years (see additional coverage information below).
  • Speech therapy/ aural rehabilitation related to cochlear implantation/ auditory brainstem implantation which extends beyond 2 years (see additional coverage information below).
  • Speech therapy/ aural rehabilitation following receipt of initial hearing aid(s) for pediatric members under age 18 which extends beyond 2 years (see additional coverage information below).
Prior authorization is not required for the following services:
  • Rehabilitative speech therapy, including
  • Feeding/ oral function therapy for adults age 18 and over (see additional coverage information below).
  • Speech therapy for cleft lip/ cleft palate for up to two years if needed (see additional coverage information below).
  • Speech therapy/ aural rehabilitation following cochlear implantation/ auditory brainstem implantation for up to two years if needed (see additional coverage information below).
  • Speech therapy/ aural rehabilitation following receipt of initial hearing aid(s) for pediatric members under age 18 for up to two years if needed (see additional coverage information below).

Coverage is subject to the indications below and any limits from your member contract.

Indications that are covered

Rehabilitative Speech Therapy
  1. Evaluation of the need for speech therapy is covered.
  2. Treatment by a speech pathologist required as a result of loss of speech due to illness and/or injury is covered.
Feeding/ Oral Function Therapy (adults age 18 and over)
  1. Evaluation of the need for feeding/ oral motor function/ swallowing therapy is covered.
  2. Treatment by a speech pathologist required as a result of loss of feeding/ oral motor function/ swallowing ability due to illness and/or injury is covered.
For Cleft Lip/ Cleft Palate
  1. Speech therapy for children (below age 18 years) to assist in swallowing or to improve functional speech related to cleft lip/ cleft palate is considered rehabilitative and is covered for up to two years if needed.
  2. Children requiring speech therapy services beyond two years must follow the prior authorization process for habilitative speech therapy. Requests will be reviewed to determine whether the member’s speech/ swallowing deficit continues to be related to cleft lip/ cleft palate versus an underlying habilitative speech/ language/ feeding disorder. If member’s deficits are determined to be no longer related to cleft lip/ cleft palate, habilitative speech therapy criteria must be met for continued coverage of speech therapy.
Following Cochlear Implantation (CI) / Auditory Brainstem Implantation (ABI)
  1. Speech therapy and/or aural rehabilitation after cochlear implantation/ auditory brainstem implantation is considered rehabilitative and is covered for up to two years if needed.
  2. Children requiring speech therapy and/or aural rehabilitation services beyond two years must follow the prior authorization process for habilitative speech therapy. Requests will be reviewed to determine whether the member’s speech/ language deficit continues to be related to hearing loss versus an underlying habilitative speech/ language disorder. If member’s deficits are determined to be no longer related to hearing loss, habilitative speech therapy criteria must be met for continued coverage of speech therapy.
Following receipt of initial hearing aid(s)
  1. Speech therapy and/or aural rehabilitation following receipt of initial hearing aid(s) for pediatric members under age 18 is considered rehabilitative and is covered for up to two years if needed.
  2. Children requiring speech therapy and/or aural rehabilitation services beyond two years must follow the prior authorization process for habilitative speech therapy. Requests will be reviewed to determine whether the member’s speech/ language deficit continues to be related to hearing loss versus an underlying habilitative speech/ language disorder. If member’s deficits are determined to be no longer related to hearing loss, habilitative speech therapy criteria must be met for continued coverage of speech therapy.

Indications that are not covered

  1. Treatment of dialect and accent reductions because it does not meet rehabilitative criteria.
  2. Speech therapy to improve speech for a second language.
  3. Group therapy.
  4. Therapy when functional improvement is not expected, or when progress has plateaued.
  5. Voice therapy for any of the following indications:
    1. Vocational/recreational related purposes such as school teacher, choir member, etc.
    2. Chronic laryngitis
    3. Maintenance care or other non-rehabilitative therapies
    4. Progress where functional improvement is not expected.

Definitions

Rehabilitative speech therapy - therapy following a loss of previous function due to an illness or injury. The therapy is performed for the purpose of obtaining significant functional improvement, within a predictable period of time (2 months), toward a maximum potential ability to perform functional activities. This is generally provided by speech pathologists, but may include other practitioners.

Note: Speech therapy for developmental conditions is considered habilitative and requires prior authorization.

Products

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.

References

  1. American Speech-Language-Hearing Association. (1993). Definitions of communication disorders and variations [Relevant Paper]. Available from www.asha.org/policy.
  2. American Speech-Language-Hearing Association. (2000). Clinical indicators for instrumental assessment of dysphagia [Guidelines]. Available from www.asha.org/policy.
  3. American Speech-Language-Hearing Association. (2001). Knowledge and skills required for the practice of audiologic/ aural rehabilitation [Knowledge and Skills.] Available from www.asha.org/policy.
  4. American Speech­Language­Hearing Association. (2004). Admission/discharge criteria in speech-language pathology [Guidelines]. Available from www.asha.org/policy.
  5. American Speech-Language-Hearing Association. (2005). The role of the speech-language pathologist in the performance and interpretation of endoscopic evaluation of swallowing: position statement [Position Statement]. Available from www.asha.org/policy.
  6. Blevins, N. H. Presbycusis. In: UpToDate, Deschler, D. G., & Sokil, H. N. (Eds.), UpToDate, Waltham, MA. (Accessed on November 4, 2016.)
  7. Goldberg, D. M., & Flexer, C. (2001). Auditory-verbal graduates: outcome survey of clinical efficacy. Journal of the American Academy of Audiology, 12, 406-414.

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Policy activity

  • 01/01/1994 - Date of origin
  • 07/21/2017 - Effective date
Review date
  • 11/2016
Revision date
  • 05/16/2017

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