Coverage Policies

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INDEX:

Effective Date: 09/18/1995

Title: Speech Therapy; Swallowing Dysfunction

Revision Date: 06/01/2018

Document: BI067:00

CPT Code(s): 92506-92508, 92521-92526, G0153, S9128, V5362-V5364

Public Statement

Effective Date:

a) This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1) Medically necessary speech therapy services are covered under specific contract benefit limits. Speech therapy must be ordered by a physician.

2) Examples of conditions that may be eligible for rehabilitative speech therapy coverage include (but are not limited to):

a) Members whose speech was lost secondary to injury or disease

b) Members whose swallowing was lost secondary to injury or disease

3) Speech therapy for habilitative purposes (for congenital disabilities or developmental delays) is only covered by certain plans—see your coverage documents and BI 398.

4) Therapy for the purpose of maintaining a current speech level is not eligible for speech therapy coverage.

5) Speech therapy may be available through either the public or the private school system. Therapy that is provided within a school is not a covered benefit. When therapy could have been provided through a public school but is not available because the patient is attending private school, substitute therapy will not be covered.

Medical Statement

1) Medically necessary speech therapy services are covered if:

a) The diagnosis is appropriately treated by speech therapy; AND

b) It is within the contract benefit limits for speech therapy; AND

c) Significant functional improvement is expected within a predicted time period as a result of speech therapy; AND

d) The speech therapy is ordered by a physician; AND

e) Evaluation and treatment are provided by a licensed speech and language pathologist.

2) Examples of conditions that may be eligible for rehabilitative speech therapy coverage include (but are not limited to):

a) Members whose speech was lost secondary to injury or disease

b) Members with difficulty in swallowing following stroke or other neurologic injury.

3) NOTE: Benefits for coverage of speech therapy is limited by the member’s benefit contract. There is usually a numerical limit on the number of sessions – consult the member’s contract and benefit summary table for specifics.

4) Habilitative/developmental speech therapy (for congenital disabilities or developmental delays) is only covered by certain plans—see policy BI398.

Codes Used In This BI:

92506	Speech evaluation
92507	Speech therapy
92508	Speech therapy, group
92521	Evaluation of Speech Fluency
92522	Evaluation of Sound Production
92523	Evaluation of Language Comprehension & Expression
92524	Analysis of Voice and Resonance
92526	Tx of Swallowing Dysfunction and/or Oral Function for Feeding
S9128	Speech therapy, in the home,
V5362	Speech screening
V5363	Language screening
V5364	Dysphagia screening

G0153 Services performed by a qualified speech-language pathologist in the

Home health or hospice setting, each 15 minutes

Limits

Speech therapy is covered as an individualized, one-on-one intervention and not as a group (92508).

Application to Products

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.