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Medical Policy

Policy Num:      08.001.004
Policy Name:    Speech Therapy
Policy ID:          [08.001.004]  [Ar / B / M+ / P]  [8.03.04]

Last Review:      November 26, 2024
Next Review:      Policy Archived
 

ARCHIVED

Related Policies:   08.003.003 - Cognitive Rehabilitation

Speech Therapy

Summary

Developmental language disorder is the most common developmental disability of childhood, occurring in 5 to 10 percent of children.   Children learn language in early childhood; later they use language to learn. Children with language disorders are at increased risk for difficulty with reading and written language when they enter school .  Early intervention may prevent the more serious consequences of later learning disabilities.

Objective

The objective of this evidence based review is to evaluate Speech therapy to treat a broad range of speech and language delays and disorders.

Policy Statements

Speech Therapy services are considered for payment when:

• They are prescribed or recommended by a doctor for the purpose of restoring or improving function in a patient with a physical impairment in phonation, due to illness, trauma, congenital anomaly or as a result of a therapeutic intervention, AND

• The patient is expected to achieve measurable improvement in a predictable and reasonable period of time (usually four to six months), AND

• Provide effective, specific and reasonable treatment for patient's diagnosis and physical condition, AND

• They are provided according to a treatment plan, where changes in patient's condition are evaluated, documented, and are certified by a doctor at least every thirty (30) days where the following is included:   

1. The date of onset or exacerbation of the disorder/diagnosis;
2. The speech therapy evaluation;
3. Specific statements of long-term and short-term goals that are specific, quantifiable (measurable) and objective;
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, which must be medically necessary and consistent with generally accepted standards of practice for speech therapy.

• The speech therapy services provided must be of the complexity and nature to require that they are performed by a licensed speech-language pathologist; and

• Services that cannot be reasonably taught and implemented by a family member, and

• Do not duplicate services covered by any other type therapy being received.

Speech therapy often occurs in the school environment or in developmental language centers. Speech therapy is not covered for payment for any of the following conditions:

• Speech dysfunction that in itself is corrected alone, such as errors in articulation in children who are not related to a specific medical condition.

• Maintenance therapies aimed at preserving the present level of function and avoiding regression of that function, including services to maintain function using methods or procedures using routines, repetition or reinforcement.

• Procedures that can be effectively performed by family members, teachers, guardians/guardians or the patient himself.

• Developmental disorders not related to a medical condition, including but not limiting itself to:

• Psychosocial language delay
• Behavioral Disorders
• Attention Deficit
• Conceptual Disorders mental retardation developmental delay
• Stuttering, babbling

Policy Guidelines

Speech therapy sessions must meet the following criteria:

1. Treat the needs of the patient with difficulty in communication.

2. Achieve the improvement goal in a predictable and reasonable period of time.

3. Provide reasonable, specific and effective treatment for the diagnosis and physical condition of the patient.

4.  Speech therapy services must be performed by a duly licensed and certified provider. All services provided must be within the applicable scope of practice for the provider in their licensed jurisdiction where the services are provided

The speech therapy care plan should include:

1. Specific status of short and long-range goals.

2. Measurable objectives.

3. A reasonable estimate of when the goal can be achieved.

4. Specific treatment techniques in activities to be used in the treatment.

5. The frequency and duration of treatment.

Speech and language assessment (92521, 92522, 92523, 92524) are considered to develop a written work plan for the patient. The purpose of the written plan of care is to assist in determining medical necessity. Up to three evaluation sessions may be considered medically necessary to evaluate the patient and to develop a written plan of care once a year.

Therapy session, up to one hour of speech therapy (92507) is payed once per day. Multiple ST (92507) sessions on the same day are applied collectively as a single daily session to the benefit limit. Progress evaluation of therapy is considered to be included in the payment of the therapy session. This should be documented in the notes or progress report of the Therapy.

It is hoped that, by providing speech therapy service to the patient, the speech therapist provide training to the family member or caregiver to facilitate their participation and assume their intervention in therapies to ensure the continued improvement and maintenance of Program.

Benefit Application

BlueCard/National Account Issues

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

According to Law 163 of August 13, 2024 - “Law for the Protection, Security, Integration, Well-being and Comprehensive Development of People with Autism Spectrum Disorders”, medical plans are obliged to offer coverage for all health interventions scientifically validated as effective for Autism Spectrum Disorders and may not establish limitations regarding age, limit of benefit, or number of visits to a medical services professional, once medical necessity has been established by a licensed physician.

Background

Speech and Language Evaluation

In some cases of speech and language impairment, an etiology can be determined and an appropriate intervention strategy can be initiated. A hearing aid, as an example, can be prescribed for a child with a language disorder resulting from hearing loss, whereas surgery may be considered for a resonance disorder secondary to nasal polyps or enlarged adenoids. By comparison, for many speech and language disorders, the etiology cannot be clearly identified, or the disorder is one manifestation of a larger condition. In these cases, the goals of the assessment are to describe the impairment and recommend a plan for intervention [11]. A case illustrating the major features of the speech and language evaluation is presented separately. (See "Case illustrating the evaluation of speech and language impairment in children".)

History — The adequacy of the child's speech and language skills should be assessed in relation to the norm and to his or her cognitive ability. The speech and language pathologist uses data gathered from various sources to perform this assessment:

●History obtained from the child's parents

●Medical history

●School history

●Previous evaluations (eg, hearing, vision, intelligence, emotional)

●Test results and observations derived from contact with the child

A parental history can be obtained with a questionnaire that includes detailed developmental, medical, social, behavioral, and school histories and a description of the parents' perception of the problem. For school-age children, having information from teachers regarding performance in the language, social, academic, and behavioral areas is helpful.

Initial evaluation — The clinician asks the parents questions that clarify or enhance information that has been submitted on the questionnaire. The responses on the questionnaire and the interview provide data that help to determine whether the child has had a favorable, stimulating environment in which to develop speech and language skills at a level consistent with his or her chronologic age and overall potential.

Information about the child's cultural and linguistic background is necessary to appropriately assess and treat speech and language impairment. Children who are more proficient (dominant) in a language other than English should have at least part of their evaluation conducted in their dominant language. Children who speak a language other than English should be tested in their native language; evaluations should be performed by a speech language pathologist who is fluent in the child's native language. An interpreter must be employed if a fluent speech and language pathologist is not available. Potential problems in the use of interpreters include errors in translation, failure of the interpreter to share information from the case history interview, and a tendency of the interpreter to minimize problems. The occurrence of such problems can be reduced by thoroughly training interpreters in the diagnostic process.

Standardized tests — The value of standardized tests as the sole tool for the assessment of communication problems has been challenged because "standardized tests destroy the fundamental social-interactive quality of communication. Many of the tests attempt to isolate and measure particular aspects of communication" without considering the others. However, some objective tests do provide quantitative measures of a child's specific skills. In addition, objective scores often are necessary for placement in special education programs and are useful for subsequent comparison. Standardized assessment tools that are chosen carefully and used appropriately provide worthwhile information.

The child's performance in specific speech and language areas, such as phonologic ability, vocabulary comprehension, and grammatic usage, is measured objectively using the most recently standardized, norm-referenced tests for a particular age group. No uniformly applicable test battery for this assessment exists; the clinician uses his or her expertise to select from among the large number of tests available.

Observation and qualitative analysis of performance — Observation and qualitative analysis of the child's performance supplement objective test results and are essential for making a diagnosis and devising a treatment plan. In the very young or uncooperative child, parental report and observation of the child at play provide the information necessary to make judgments about the precursors of speech and language development: the adequacy of speech and language, nonverbal cognition, and social interaction. Precursors of normal speech and language development are listed in the table.

For older children, the clinician can gather important data about the child's ability to communicate in conversational situations through close observation during informal interaction with the child or watching the child's interaction with his parent or sibling. In the qualitative analysis, the skilled clinician looks at how the child arrived at the answer, instead of whether the answer was right or wrong. As an example, does the child:

●Require repetition or shortening of the question to understand it?

●Use his or her hands excessively or grope for words during responses?

●Run out of breath while talking?

●Become dysfluent or hypernasal as the length of the stimulus increases?

●Demonstrate appropriate problem-solving strategies?

●Show poor ability to respond to suggestions?

●Require excessive time for comprehending and/or responding?

The clinician should note the kinds of test modifications that were helpful to the child, such as repeating instructions and stressing key words, shortening the length of the stimulus, prodding or encouraging to take risks, requiring eye contact during oral instruction, or encouraging repetition of instruction before proceeding. These subjective observations provide valuable information for making the diagnosis and for devising a management plan.

Instrumented observation — Computers, fiberoptic instruments, and radiologic studies augment the evaluation of swallowing, voice, and resonance disorders. As examples, computers are used to analyze the acoustic properties of voice and speech; the vocal folds can be viewed directly with fiberoptic instruments; and videofluorography assists in the examination of the oral mechanism during speaking and swallowing.

Reporting results — The final report should include the following information:

●The nature of the problem

●A description of how the problem affects the child's function

●The strengths of the child that will enable him or her to compensate for the weaknesses

●Recommendations for management

●A program for implementing the recommendations

The clinician should communicate this information to the child's parents at a conference and in writing. The clinician can choose to have the child present at this meeting or to have a separate conference with the child to present the information at a level that he or she will understand.

A definitive diagnosis cannot always be made during the initial assessment. In these cases, the assessment provides a baseline for comparison with follow-up assessment (monitoring). Diagnostic therapy may be recommended for those children for whom more observation is necessary before arriving at a diagnosis or determining a management plan (eg, children who are frightened in the clinical setting).

Specific suggestions for appropriately stimulating language should be given to parents, teachers, and others involved in the child's care. As an example, providing a language model that is appropriate to the child's linguistic development (eg, sounds, single words, phrases, simple sentences) is important. Parents may be advised to comment about daily activities rather than overusing direct questioning that may decrease verbal output from the child. Parents are encouraged to accept less than perfect productions (eg, word approximations) when the child's intent is clear. In a systematic review, better language outcomes were achieved when parents were taught how, specifically, to stimulate language in their children.

Children with speech and oral language disorders are at high risk for developing learning disabilities (eg, academic problems) when they enter school. Parents should know how to advocate for their children in the school system by making sure they get the services they need and ensuring the condition is monitored through periodic reevaluation.

Specific interventions — Management of speech and language impairment may include one or more of the following:

●Enrollment in individual or group speech and language therapy

●Therapy through a private facility or the public-school system

●Attendance at a specialized school for children with speech, language, and learning differences

●Further assessment in specific areas (eg, oral motor function, general motor function, psychologic)

●Application of assistive technology

●Periodic monitoring without direct therapy

Timing of intervention —  Though few studies have examined the effect of timing of intervention on outcome, early intervention usually is recommended. This preference was illustrated in a study in which 30 preschool-age children with severe phonologic disorders were randomized to receive four months of therapy followed by four months of no treatment or four months of no treatment followed by four months of therapy. The children in the early therapy group had greater improvement in speech intelligibility at both four and eight months.

Early intervention also improves language skills in children with delayed language. In one study of 21 toddlers with delayed language development who were randomly assigned to early versus delayed treatment groups, the early treatment group showed improvement in each of five linguistic outcomes: mean length of utterance; total number of words; number of different words; lexical repertoire; and percentage of intelligible utterances. These children also had improved socialization skills and decreased levels of parental stress. In another small randomized trial, parent-implemented communication treatment improved speech prelinguistic skills in children between 6 and 24 months of age with moderate to profound hearing loss.

However, early intervention for delayed language may not change the long-term outcome, as illustrated in a study that examined the narrative language skills of untreated children with and without a history of delayed expressive language (ie, late talkers) as toddlers. Children with normal language skills had better narrative language skills in kindergarten and first grade than did those with language delay, but by the second grade, no difference was found among the groups.

Although many variables must be considered, and criteria may be difficult to objectify, the positive effects of lowering frustration for the child and family and maintaining the child's self-esteem render early intervention worthwhile in many cases.

Efficacy — Therapeutic outcomes have been described in diverse patient populations, including children with articulation, voice, fluency, and language disorders. Some examples include:

●Children who received phonologic treatment have demonstrated changes in their sound systems that improved overall intelligibility and communicative functioning.

●Normal oral-nasal resonance balance and articulation was achieved by age 5 years in 93 percent of 41 children with cleft palate who received direct or indirect speech services.

●In a controlled trial for the treatment of child stuttering, children who received intensive smooth speech therapy, parent-home smooth speech therapy, or intensive electromyography feedback demonstrated improvement in fluency compared with the control group at 3 and 12 months posttherapy (less than 1 percent of syllables stuttered versus no improvement). The treatment gains were maintained after an average of four years posttreatment.

●Children who were exposed to enhanced milieu teaching in their preschool classroom increased their use of targeted language skills; these changes were maintained when the treatment was discontinued.

●The field of augmentative communication has tremendously improved the ability of individuals with severe physical disability and dysarthria (eg, secondary to cerebral palsy) to communicate.

Regulatory Status

Licensure Requirements: Speech-Language Pathology and Audiology

Sec. 14. Speech-language pathologist or audiologist. (20 L.P.R.A. sec. 3114) Any person who aspires to practice the profession of speech-language pathologist or audiologist, in addition to meeting the requirements established by [20 LPRA sec. 3112] of this law, shall:

1. Possessing a bachelor's degree or its equivalent from a university accredited by the Board of Higher Education, if it operates in Puerto Rico, or in an institution recognized by a national accreditation body, if it resides in any of the states United States of America, or recognized by the Board, if it resides in another country.

2. Have obtained a master's degree or doctorate in speech-language pathology or audiology, as applicable, in a school accredited by the Higher Education Council, if it operates in Puerto Rico, or in an institution recognized by the Board, if it states of the United States, the District of Columbia or another country. Those professionals who have obtained in or before the academic year 1978-79 the master's degree in sciences with concentration in the enablement of the deaf will be included in the definition of speech pathologist, as described in the [20 LPRA sec. 3102] of this law. They shall have the same rights and duties, and shall apply to them the penalties laid down in this law.

Medicare National Coverage

National Coverage Determinations (NCDs): NCD for speech pathology services for the treatment of dysphagia. 2006. The NCD is broader in scope than the Coverage Policy. Refer to the CMS NCD table of contents link in the reference section. 

Local Coverage Determinations (LCDs): Multiple LCDs found. Refer to the LCD table of contents link in the reference section.

References

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27. Blakeley RW, Brockman JH. Normal speech and hearing by age 5 as a goal for children with cleft palate: A demonstration project. Am J Speech Lang Pathol 1995; 4:25.
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Codes

Policy History