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Rehabilitative/Habilitative Medical Criteria for Speech Therapy

Policy Number: MP-577

Latest Review Date: October 2019

Category:  Administrative

Policy Grade: Not Applicable

POLICY:

Effective for dates of service on or after January 1, 2017:

Rehabilitative and Habilitative Speech Therapy services may be considered medically necessary when used in the treatment of communication impairment or swallowing disorders due to disease, trauma, congenital anomalies, or prior therapeutic intervention and meet ALL of the following criteria:

  • The medical diagnosis is established by a physician and supports utilization of the therapy; AND
  • There is documentation of objective impaired speech, language, or swallowing impairment skills; AND
  • There is an individualized plan of care that includes treatment services that are expected to result in restoring or acquiring the level of functioning in a reasonable and generally predictable period of time as short-term therapy, usually within a three month period. The frequency and duration of services must be reasonable; AND
  • The services are one-to-one (unless otherwise stated in member specific Summary Plan Description [SPD]); AND
  • The services are skilled.  The services must be of a level of complexity and sophistication, or the condition of the patient must be such that the services required can be safely and effectively performed only by a qualified, licensed provider; AND
  • Documented by the person rendering the services; AND
  • The services must not duplicate services provided by any other therapy.

Rehabilitative and Habilitative Speech Therapy services are 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.

Rehabilitative/Habilitative speech therapy are considered not medically necessary when services that do not ordinarily require the skills of a qualified, licensed provider of speech therapy. 

Examples include:

  • The therapy is considered primarily educational.
  • Services provided when the patient’s expected restoration potential is insignificant in relation to the extent and duration of the therapy services required to achieve such potential.
  • Treatments that maintain function using routine, repetitious, or reinforced procedures that are neither diagnostic nor therapeutic
  • Procedures that may be carried out effectively by the individual, family, or caregivers
  • Maintenance care.  Maintenance care is defined as management of a patient who has reached pre-clinical status or maximum medical improvement where the condition is resolved or becomes stable.

Rehabilitative and Habilitative Speech Therapy is considered not medically necessary when the services of the speech therapist are rendered to a patient who is related to the provider by blood or marriage or who lives in the provider’s household.

* NOTE:  Please refer to the member’s Summary Plan Description for any Autism, or Autism Spectrum Disorder (ASD), and/or Applied Behavioral Analysis (ABA) Benefits. There are varying benefit plans for these services. Please verify benefits prior to applying policy criteria, as benefits will supersede this policy.

Effective for dates of service prior to January 1, 2017:

Speech therapy services may be considered medically necessary when used in the treatment of communication impairment or swallowing disorders due to disease, trauma, congenital anomalies, or prior therapeutic intervention and meet all of the following criteria:

  • The medical diagnosis is established by a physician and supports utilization of the therapy; AND
  • There is documentation of objective impaired speech, language, or swallowing impairment skills; AND
  • There is a plan of care that includes treatment services that are expected to result in improvement of the level of functioning in a reasonable and generally predictable period of time. The frequency and duration of services must be reasonable; AND
  • The services are one-to-one (unless otherwise stated in member specific Summary Plan Description [SPD]); AND
  • The services are skilled. The services must be of a level of complexity and sophistication, or the condition of the patient must be such that the services required can be safely and effectively performed only by a qualified, licensed provider; AND
  • Documented by the person rendering the services

Speech therapy services are 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.

Speech therapy is considered not medically necessary when services that do not ordinarily require the skills of a qualified, licensed provider of speech therapy.

Examples include:

  • The therapy is considered primarily educational.
  • Services provided when the patient’s expected restoration potential is insignificant in relation to the extent and duration of the therapy services required to achieve such potential.
  • Treatments that maintain function using routine, repetitious, or reinforced procedures that are neither diagnostic nor therapeutic
  • Procedures that may be carried out effectively by the individual, family, or caregivers
  • Maintenance care. Maintenance care is defined as management of a patient who has reached pre-clinical status or maximum medical improvement where the condition is resolved or becomes stable.

Speech therapy is considered not medically necessary when the services of the speech therapist are rendered to a patient who is related to the provider by blood or marriage or who lives in the provider’s household.

* NOTE: Please refer to the member’s Summary Plan Description for any Autism, or Autism Spectrum Disorder (ASD), and/or Applied Behavioral Analysis (ABA) Benefits. There are varying benefit plans for these services. Please verify benefits prior to applying policy criteria, as benefits will supersede this policy.

DESCRIPTION OF PROCEDURE OR SERVICE:

Rehabilitation is defined as services “provided to help a person regain, maintain, or prevent deterioration of a skill or function that has been acquired but then was lost or impaired due to illness, injury, or disabling condition.” An example of this would be skills lost due to a stroke.

Rehabilitation services should assist patients in restoring a necessary skill or function that would impact activities of daily living (ADLs).

Habilitation Therapy is defined as services or devices “to attain, maintain, or prevent deterioration of a skill or function never learned or acquired due to a disabling condition.” An example would be a child not walking by the expected age. 

Habilitative therapy services are intended to assist patients in acquiring (versus restoring) a necessary skill or function which impairs ADLs.

Speech Therapy is the treatment of communication impairment and swallowing disorders.  Speech therapy services facilitate the development and maintenance of human communication and swallowing through assessment, diagnosis, and rehabilitation.

Speech therapy services are intended to improve, adapt or restore functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality involving goals an individual can reach in a reasonable period of time. Benefits will end when treatment is no longer medically necessary and the individual stops progressing toward those goals.

Speech therapy covers a wide range of services for all ages, and is provided in schools, hospitals, home care, rehabilitation centers, and nursing homes. Speech therapists work with individuals who have physical or cognitive deficits/disorders resulting in difficulty communicating. Communication includes speech (articulation, voice, linguistics) and language (phonology, morphology, syntax, semantics, pragmatics, both receptive and expressive language, including reading and writing). Speech therapists treat acquired reading and writing impairments in adults and children who have previously learned how to read and write and are diagnosed with neurologic impairments.  They also provide services for individuals with dysphagia (difficulty swallowing).

KEY POINTS:

The Department of Health and Human Services has issued a Final Rule as a provision of Essential Health Benefits (EHB) (section 156.115) of the Patient Protection & Affordable Care Act (PPACA) (section 1302(b)(1)(G)) that rehabilitative and habilitative services be one of the ten categories of essential health benefits.  Effective for plan years beginning January 1, 2017, separate limits on rehabilitative and habilitative services are required.

KEY WORDS:

Speech therapy, ST, speech language therapy, SLT, habilitation, habilitative, rehabilitation, rehabilitative

Approved by Governing Bodies:

Not applicable

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply.

FEP:  Special benefit consideration may apply.  Refer to member’s benefit plan.  FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.

* NOTE:  Please refer to the member’s Summary Plan Description for any Autism, or Autism Spectrum Disorder (ASD), and/or Applied Behavioral Analysis (ABA) Benefits. There are varying benefit plans for these services. Please verify benefits prior to applying policy criteria, as benefits will supersede this policy.

CURRENT CODING: 

CPT Codes:

G0153, G0161

 Allied Health Services

V5336, V5362-V5364

 Speech-Language Pathology Services

92507-92508, 92520-92526, 92597

 Special Otorhinolaryngologic Services

92601-92612, 92614, 92616, 92618

 Evaluative & Therapeutic Services

92626 - 92633

 Auditory Rehabilitation Services

96105

 Speech Testing Services

S9128, S9152

 Other

                       

*NOTE:  When performed by a Speech Therapist, the following codes are considered part of Speech Therapy services:

V5008; 92551 – 92552; 92567; 92700

Modifier:

To report habilitation services, append the following modifier:

96

Habilitative services 

 

To report rehabilitation services, append the following modifier:

97

Rehabilitative services 

REFERENCES:

  1. American Speech-Language-Hearing Association. Roles of speech-language pathologists in the identification, diagnosis and treatment of individuals with cognitive-communication disorders: position statement. 2005. Available at: www.asha.org/docs/html/PS2005-00110.html.

  2. American Speech-Language Hearing Association. Speech and language disorders and diseases. Available at www.asha.org/public/speech/disorders/.

  3. American Speech-Language-Hearing Association. Speech sound disorders: articulation and phonological processes. Available at www.asha.org/public/disorders/SpeechSound Disorders.

  4. Brady MC, Kelly H, Godwin J, Enderby P. Speech and language therapy for aphasia following stroke. Cochrane Database Styt Rev. 2012; 5:CD000425.

  5. Coleman JJ, Venediktov RA, et al. ASHA’s Nactional Center for Evidence Based Practice in Communication Disorders. July 2013. //www.asha.org/uploadedFiles/EBSR-Impact-of-Literacy-Intervention.pdf#search=%22randomized%22.

  6. Centers for Medicare and Medicaid Services.  Department of Health and Human Services. 45 CFR Parts 144, 147, 153, 154, 155, 156, and 158. Patient Protection and Affordable Care Act; CMS-9944-F. February 27, 2015. www.federalregister.gov/articles/2015/02/27/2015-03751/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2016 Last accessed July, 201

  7. Lewis BA, Freebairn L. Residual effects of preschool phonology disorders in grade school, adolescence, and adulthood. J Speech Hear Res. 1992; 35 (4): 819-831.

  8. Meinzer M. 2005 June. Intense therapy improves speech after stroke. Available at: www.webmd.com/stroke/news/20050609/intense-therapy-improves-speech-after -stroke.

  9. Pennington L, Goldbart J, Marshall J. Speech and language therapy to improve the communication skills of children with cerebral palsy. Cochrane Database Syst Rev. 2003; (3): CD003466.

  10. Scarborough, HS, Dobrich W. Development of children with early language delay. J Speech Hear Res. 1990; 33 (1): 70-83.

POLICY HISTORY:

Medical Policy Group, March 2015 (3):  New policy developed around current speech therapy benefits. No change in coverage.

Medical Policy Administration Committee, April 2015

Available for comment, March 24 through May 7, 2015

Medical Policy Group, March 2016 (4): Update to Description, Key Points, Key Words, Coding and References.

Medical Policy Group, November 2016 (3):  Update to Title, Description, Key Points, Key Words, Coding and References; Policy Statements updated to reflect clarifying current services as “rehabilitative” and adding “habilitative” services effective 01/01/17. 

Medical Policy Administration Committee, November 2016

Available for comment November 10 through December 26, 2016

Medical Policy Group, December 2017 (3):  2017 Updates to Coding & Previous Coding sections due to 2018 Coding update; clarified benefit note regarding autism, ASD, ABA; no change in policy statement;  other 2018 Coding update information added as well (note – new, revised and deleted codes fell within ranges so no edits needed)

Medical Policy Group, October 2019 (7):  2019 Update- Removed Previous Coding section. No change in policy statement.

Medical Policy Group, December 2019 (6): 2020 Annual Coding update, revised 92626/92627.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

  1. The technology must have final approval from the appropriate government regulatory bodies;
  2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
  3. The technology must improve the net health outcome;
  4. The technology must be as beneficial as any established alternatives;
  5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

  1. In accordance with generally accepted standards of medical practice; and
  2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
  3. Not primarily for the convenience of the patient, physician or other health care provider; and
  4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.