Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

For coverage information on high tech imaging (MRI, CT, PET) and nuclear medicine, administered by Evicore, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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.