MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 1

Original Issue Date (Created): July 1, 2002

Most Recent Review Date (Revised): May 20, 2014

Effective Date: October 1, 2014

I. POLICY

Speech therapy services may be considered medically necessary when the services are

reasonable and necessary for the treatment of the individual’s illness or injury and an

expectation exists that the therapy will result in a significant and measurable improvement in

the individual’s level of functioning within a reasonable period of time (i.e., approximately 3-4

months) and the improvement is documented at 3-4 month intervals.

Treatment should be provided by a speech therapist, speech pathologist, or speech clinician in

accordance with a written plan of care as appropriate for the diagnosis. The plan of care should

include:

Patient’s significant past history;

Patient’s diagnoses that require speech therapy;

Name of the attending physician and any related physician orders;

Therapy goals, both short and long term, and potential for achievement, including

measureable objectives and a reasonable estimate of when goals may be reached;

Any contraindications;

Patient’s awareness and understanding of diagnosis, prognosis, and treatment goals;

When appropriate, the summary of treatment provided and results achieved during

previous periods of speech therapy services; and

Specifics of the type of treatment, including amount, frequency and duration of

activities

Speech therapy may be considered medically necessary when it is directed to the active

treatment of at least one of the following conditions:

Autism spectrum disorders (see cross-reference).

Childhood Speech delay due to congenital hearing loss or disease (e.g. recurrent otitis

media etc.).

Congenital craniofacial anomalies (e.g., cleft palate and lip).

POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND

RATIONALE DEFINITIONS BENEFIT VARIATIONS

DISCLAIMER CODING INFORMATION REFERENCES

POLICY HISTORY

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 2

Disease (e.g., post-cerebrovascular accident);

Medical/biological voice dysfunctions with vocal cord lesions or movement

abnormalities.

Previous therapeutic interventions (e.g., esophageal training following laryngectomy)

Swallowing disorders (e.g., dysphagia), regardless of the presence of a

communication disability;

Trauma (e.g., subdural hematoma influencing the speech center).

Pediatric or Developmental Disorders or Delays * that are documented as resulting in

speech less than the 20th percentile (more than 1 standard deviation less than the

norm) or a 15% age delay on standardized testing. Scaled score norms are usually 10

with a standard deviation of +/- 3, or Standard Scores of 100 with a standard

deviation of 15. These Disorders or Delays include the following: Childhood stuttering and stammering severe or present for more than 6 months,

under nine years of age; or

Childhood speech apraxia that is not part of a global developmental delay; or

Disarticulation, articulation disorder; or

Dysarthria; or

Expressive language disorder or delay; or

Phonologic delay, or

Receptive language disorder or delay

*Speech therapy for the treatment of pediatric developmental disorders or delays (listed above)

will require re-evaluation every 3-4 months by the Plan’s medical director. Repeat testing,

objective if applicable, must show that percentile scores improve or that age equivalent scores

improve more than age change. Also, see plan of care requirements listed above in the policy.

Outpatient speech therapy (ST) services may be considered medically necessary as outlined in

the guidelines set forth in this policy and further described in the Centers for Medicare and

Medicaid Services (CMS), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15,

Section 220 (as may be amended from time to time).

Speech therapy services are considered not medically necessary for the following conditions:

Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder

Auditory Conceptual Dysfunction or conceptual handicap (see definitions).

Behavioral problems (including impulsive behavior and impulsivity syndrome)

Developmental listening delay.

Grammatic delays treated by services that are primarily educational in nature (e.g.

use of pronouns, plural/singular words, syntax, semantics, etc.);

Individuals with an intellectual disability, except when disorders such as aphasia or

dysarthria are present.

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 3

Mild delays that are likely amenable to normal parental and classroom training,

corresponding to standardized test results approximately above the 20th percentile or

less than 15% age delay.

Maintenance therapy services except for individuals whose benefits are subject to

the terms mandated in the Pennsylvania Act 62 of 2008, Section 635.2, Autism

Spectrum Disorders Coverage. (See MP-2.304, Pervasive Developmental Disorders.)

Neuromuscular electrical stimulation therapy for the treatment of dysphagia (e.g.

VitalStim®).

Pediatric Symbolic Dysfunction (i.e. pediatric agnosia).

Pragmatic or Social Communication disorder or delay, including but not limited to

conversational turn-taking or topic maintenance, color identification, etc.

Psychosocial speech delay

Reduced phonological awareness.

Severe global delay evidenced by delay in multiple areas of comprehension,

expression and organization of speech, and/or speech motor abnormality.

Central Auditory Processing Disorder (CAPD) testing or treatment is considered

investigational. There is insufficient evidence to support a conclusion concerning the health

outcomes or benefits associated with this procedure.

Cross-reference: MP-8.007 Cognitive Rehabilitation

MP-8.004 Occupational Therapy (Outpatient)

MP-2.304 Pervasive Developmental Disorders

MP-8.001 Physical Medicine and Specialized Physical Medicine Treatments (Outpatient)

MP-8.011 Sensory Integration Therapy

MP-6.032 Speech Generating Devices

II. PRODUCT VARIATIONS TOP [N] = No product variation, policy applies as stated

[Y] = Standard product coverage varies from application of this policy, see below

[N] Capital Cares 4 Kids [N] Indemnity

[N] PPO [N] SpecialCare

[N] HMO [N] POS

[Y] SeniorBlue HMO* [Y] FEP PPO**

[Y] SeniorBlue PPO*

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 4

* Refer to Novitas Solutions Inc, (LCD) L27531 Speech Language Pathology (SLP) Communication

Disorders

*Refer to Medicare Benefit Policy Manual 100-02, Chapter 15, Section 80.3 Tests of auditory processing

may be a covered benefit.

**The FEP program dictates that all drugs, devices or biological products approved by the U.S.

Food and Drug Administration (FDA) may not be considered investigational. Therefore, FDA-

approved drugs, devices or biological products may be assessed on the basis of medical

necessity.

III. DESCRIPTION/BACKGROUND TOP

Speech Therapy includes those services necessary in the diagnosis and treatment of speech and

language disorders which result in communication disabilities, and services required in the

diagnosis and treatment of swallowing disorders, regardless of the presence of a communication

disability.

(Central) Auditory Processing (C)AP refers to the efficiency and effectiveness by which the

central nervous system (CNS) utilizes auditory information. Narrowly defined, (C) AP refers to

the perceptual processing of auditory information in the CNS and the neurobiologic activity that

underlies that processing and gives rise to electrophysiologic auditory potentials. (C)AP

includes the auditory mechanisms that underlie the following abilities or skills: sound

localization and lateralization; auditory discrimination; auditory pattern recognition; temporal

aspects of audition, including temporal integration, temporal discrimination (e.g., temporal gap

detection), temporal ordering, and temporal masking; auditory performance in competing

acoustic signals (including dichotic listening); and auditory performance with degraded acoustic

signals

(Central) Auditory Processing Disorder, (C) APD refers to difficulties in the perceptual

processing of auditory information in the CNS as demonstrated by poor performance in one or

more of the above skills. Although abilities such as phonological awareness, attention to and

memory for auditory information, auditory synthesis, comprehension and interpretation of

auditorily presented information, and similar skills may be reliant on or associated with intact

central auditory function, they are considered higher order cognitive communicative and/or

language-related functions and, thus, are not included in the definition of (C) AP.

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 5

IV. RATIONALE TOP

Central Auditory Processing

As indicated by American Speech-Language Hearing Association’s technical report indicates

“At this time, there is no universally accepted method of screening for (C)APD. There remains a

need for valid and efficient screening tools for this purpose. It is important to emphasize that

screening tools should not be used for diagnostic purposes.”

The National Institute on Deafness and Communication Disorders notes that much research is still

needed to understand CAPD problems, related disorders, and the best intervention for each child

or adult. Researchers are currently studying a variety of approaches to treatment. At this time

treatment and management are dependent upon the deficit that is displayed. No pharmacologic

agent has shown to be effective specifically for (C)APD. Interventions for (C)APD focuses on

improving the quality of the acoustic signal and the listening environment, improving auditory

skills, and enhancing utilization of metacognitive and language resources.

British Society of Audiologists Practice Guidance also reports the following:

At this time there is no ‘gold standard’ for diagnosing APD. Without such a

‘gold standard’, the best methods for identifying and managing APD remain

elusive. Data specifically addressing the efficacy of interventions for APD

are lacking and many of the recommendations commonly made are based on

theory or inferred from approaches validated in other populations, e.g.

specific language impairment and dyslexia.

Researchers are demanding empirical evidence before endorsing diagnostic

criteria and intervention strategies whilst clinicians, seeing individuals with

‘suspected APD’, are demanding guidelines for best practice at this time.

The translation of evidence into practical recommendations is likely to take

some time and it is important that researchers and clinicians collaborate in

their efforts.

In general, an overview of the literature reveals numerous articles describing various tests of

central auditory processing. It would appear that the concept of such testing is widely accepted

among the medical and audiology community. This acceptance challenges the determination that

tests of CAP would still be considered investigational; however, an evidence-based approach to

their evaluation is limited due to the multiple different batteries of tests that have been explored,

the lack of a gold standard test for comparison, the heterogeneous nature of patients that have

been tested (based both on age and symptoms), and the uncertain impact on the overall health of

the patient. In 1996, the American Speech Language Hearing Association published a task force

report on CAP and noted that there was persistent controversy over CAP and its disorders and

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 6

how it should be defined, identified, and ameliorated through intervention. These same concerns

were echoed in a subsequent reports.

V. DEFINITIONS TOP

(Including diagnoses with their associated tests, if applicable)

APHASIA is a total or partial loss of the ability to use or understand language; usually caused by

stroke, brain disease, or injury.

APRAXIA OF SPEECH refers to a disorder of the nervous system that affects the ability to

sequence and say sounds, syllables, and words. Tests: Oral Motor Examination, Melody of

Speech Assessment, Articulation Evaluation.

AUDITORY CONCEPTUAL DYSFUNCTION OR CONCEPTUAL HANDICAP is an impairment in the

primary sensory-cognitive function that is basic to reading and spelling. Inability to make

precise judgments as to how syllables and words match or differ.

AUDITORY PERCEPTUAL PROCESSING DISORDER is also known as an auditory perceptual

problem, central auditory dysfunction or central auditory processing disorder. It is a condition

wherein a person does not process speech/language correctly. They may have difficulties

knowing where sound has occurred and identifying the source of the sound or in distinguishing

one sound from another. Tests – Test of Central Auditory Processing with abnormal repetition

of words spoken with and without background noise, Test of Auditory-Perceptual Skills-

Revised (TAPS-R), Test of Auditory Processing and Reasoning, Clinical Evaluation of

Language Fundamentals-3 (CLEF-3).

DYSARTHRIA is a motor speech disorder that is due to a paralysis, weakness, altered muscle tone

or incoordination of the speech muscles. Speech is slow, weak, imprecise or uncoordinated.

Test - Oral-motor exam.

DYSARTICULATION OR ARTICULATION DISORDERS are disorders of the quality of speech

characterized by the substitution, omission, distortion, and addition of phonemes. Tests -

Goldman-Fristoe Test of Articulation, Patterned Articulation Test (PAT).

DYSPHAGIA is difficulty with swallowing.

EXPRESSIVE LANGUAGE DISORDER OR DELAY is a delay in vocabulary, tenses, word recall or

production of sentences with developmentally appropriate length or complexity. Tests - Clinical

Evaluation of Language Fundamentals-3 (CLEF-3) Expressive language subtests, Testing of

Language Development Primary for under 3 year old, Preschool Language Scale-4 (PLS-4) for

1-4 year olds, Expressive 1 Word Vocabulary Test for 1-6 year olds.

GRAMMATIC DELAY is delay in use of pronouns, plural – singular, syntax, semantics, etc.

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 7

MAINTENANCE PROGRAM is a therapy program that consists of activities that preserve the

patient’s present level of function and prevents regression of that function. Maintenance begins

when the therapeutic goals of a treatment plan have been achieved or when no further progress

is apparent or expected to occur.

PHONEME is the smallest sound unit which, in terms of the phonetic sequences of sound,

controls meaning.

PHONOLOGIC DELAY is a disorder characterized by failure to use speech sounds that are

appropriate for the individual's age and dialect. Symptoms typically include but are not limited

to failure in sound production and use, substitutions of one sound for another, and omissions of

sounds. Test - Goldman-Fristoe Test of Articulation.

PSYCHOSOCIAL SPEECH DELAY REFERS to speech delay resulting from psychosocial

deprivation, (i.e. the absence of appropriate stimuli in the physical or social environment which

are necessary for the emotional, social, and intellectual development of the individual.)

RECEPTIVE LANGUAGE DISORDER OR DELAY is a difficulty understanding words, sentences, or

age appropriate extended discourse. Tests - Clinical Evaluation of Language Fundamentals-3

(CLEF-3) Receptive language subtests, Preschool Language Scale-4 (PLS-4), Testing of

Language Development Primary, Receptive 1 Word Vocabulary Test for 1-6 year olds.

REDUCED PHONOLOGICAL AWARENESS describes problems in rhyming, isolation, deletion and

blending of phonemes and graphemes. Test – Pattern Awareness Test (PAT)

VI. BENEFIT VARIATIONS TOP

The existence of this medical policy does not mean that this service is a covered benefit under

the member's contract. Benefit determinations should be based in all cases on the applicable

contract language. Medical policies do not constitute a description of benefits. A member’s

individual or group customer benefits govern which services are covered, which are excluded,

and which are subject to benefit limits and which require preauthorization. Members and

providers should consult the member’s benefit information or contact Capital for benefit

information.

VII. DISCLAIMER TOP Capital’s medical policies are developed to assist in administering a member’s benefits, do not constitute medical

advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of

members. Members should discuss any medical policy related to their coverage or condition with their provider

and consult their benefit information to determine if the service is covered. If there is a discrepancy between this

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 8

medical policy and a member’s benefit information, the benefit information will govern. Capital considers the

information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law.

VIII. CODING INFORMATION TOP Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The

identification of a code in this section does not denote coverage as coverage is determined by the

terms of member benefit information. In addition, not all covered services are eligible for separate

reimbursement.

Covered when medically necessary:

CPT Codes® 92507 92508 92521 92522 92523 92524 92526 92610 92611

Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved.

*If applicable, please see Medicare LCD or NCD for additional covered diagnoses.

HCPCS

Code Description

G0153 Services of a speech and language pathologist in home health or hospice settings, each 15 minutes

G0451 Development testing, with interpretation and report, per standardized instrument form

G0161

Services performed by a qualified speech-language pathologist, in the home health setting, in the

establishment or delivery of a safe and effective speech-language pathology maintenance program,

each 15 minutes

S9128 Speech therapy, in the home, per diem

S9152 Speech therapy, re-evaluation

ICD-9-CM

Diagnosis

Code*

Description

146.0 –

146.9 MALIGNANT NEOPLASM OF TONSIL

148.0 –

148.09 MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX

149.0 –

149.99 MALIGNANT NEOPLASM OF PHARYNX, UNSPECIFIED

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 9

ICD-9-CM

Diagnosis

Code*

Description

161.0 –

161.9 MALIGNANT NEOPLASM OF GLOTTIS

161.2 MALIGNANT NEOPLASM SUBGLOTTIS

161.3 MALIGNANT NEOPLASM LARYNGEAL CARTILAGES

161.8 MALIGNANT NEOPLASM OTHER SPECIFIED SITES OF LARYNX

161.9 MALIGNANT NEOPLASM LARYNX UNSPECIFIED

191.1 –

191.9 MALIGNANT NEOPLASM OF FRONTAL LOBE OF BRAIN

198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD

198.4 SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS

SYSTEM

225.0 BENIGN NEOPLASM OF BRAIN AND OTHER PARTS OF NERVOUS SYSTEM,

BRAIN

235.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF DIGESTIVE AND RESPIRATORY

SYSTEMS, LARYNX

239.1 NEOPLASM OF UNSPECIFIED NATURE OF RESPIRATORY SYSTEM

239.6 NEOPLASM OF UNSPECIFIED NATURE OF BRAIN

299.00 AUTISTIC DISORDER, CURRENT OR ACTIVE STATE

299.01 AUTISTIC DISORDER, RESIDUAL STATE

299.10 CHILDHOOD DISINTEGRATIVE DISORDER, CURRENT OR ACTIVE STATE

299.11 CHILDHOOD DISINTEGRATIVE DISORDER, RESIDUAL STATE

299.80 OTHER SPECIFIED PERVASIVE DEVELOPMENTAL DISORDERS, CURRENT

OR ACTIVE STATE

299.81 OTHER SPECIFIED PERVASIVE DEVELOPMENTAL DISORDERS, RESIDUAL

STATE

299.90 UNSPECIFIED PERVASIVE DEVELOPMENTAL DISORDER, CURRENT OR

ACTIVE STATE

299.91 UNSPECIFIED PERVASIVE DEVELOPMENTAL DISORDER, RESIDUAL STATE

307.0 ADULT ONSET FLUENCY DISORDER

310.8 OTHER SPECIFIED NONPSYCHOTIC MENTAL DISORDER FOLLOWING

ORGANIC BRAIN DAMAGE

315.00 DEVELOPMENTAL READING DISORDER, UNSPECIFIED

315.01 ALEXIA

315.02 DEVELOPMENTAL DYSLEXIA

315.09 OTHER SPECIFIC DEVELOPMENTAL READING DISORDER

315.2 OTHER SPECIFIC DEVELOPMENTAL LEARNING DIFFICULTIES

315.31 EXPRESSIVE LANGUAGE DISORDER

315.32 MIXED RECEPTIVE-EXPRESSIVE LANGUAGE DISORDER

315.34 SPEECH AND LANGUAGE DEVELOPMENTAL DELAY DUE TO HEARING

LOSS

315.35 CHILDHOOD ONSET FLUENCY DISORDER

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 10

ICD-9-CM

Diagnosis

Code*

Description

315.39 OTHER DEVELOPMENTAL SPEECH OR LANGUAGE DISORDER

315.4 DEVELOPMENTAL COORDINATION DISORDER

315.5 MIXED DEVELOPMENT DISORDER

315.8 OTHER SPECIFIED DELAY IN DEVELOPMENT

318.0 MODERATE MENTAL RETARDATION

318.1 SEVERE MENTAL RETARDATION

318.2 PROFOUND MENTAL RETARDATION

330.0-

330.9 CEREBRAL DEGENERATIONS USUALLY MANIFEST IN CHILDHOOD

331.0 ALZHEIMER'S DISEASE

332.0 PARALYSIS AGITANS

332.1 SECONDARY PARKINSONISM

333.0 OTHER DEGENERATIVE DISEASES OF THE BASAL GANGLIA

333.2 MYOCLONUS

333.4 HUNTINGTON'S CHOREA

333.81 REYE'S SYNDROME

333.90 UNSPECIFIED EXTRAPYRAMIDAL DISEASE AND ABNORMAL MOVEMENT

DISORDER

335.20 AMYOTROPHIC LATERAL SCLEROSIS

341.0 NEUROMYELITIS OPTICA

342.00 FLACID HEMIPLEGIA AFFECTING UNSPECIFIED SIDE

348.9 UNSPECIFIED CONDITION OF BRAIN

352.1 GLOSSOPHARYNGEAL NEURALGIA

352.2 OTHER DISORDERS OF GLOSSOPHARYNGEAL (9TH) NERVE

352.3 DISORDERS OF PNEUMOGASTRIC (10TH) NERVE

352.4 DISORDERS OF ACCESSORY (11TH) NERVE

352.5 DISORDERS OF HYPOGLOSSAL (12TH) NERVE

352.6 MULTIPLE CRANIAL NERVE PALSIES

388.40 UNSPECIFIED ABNORMAL AUDITORY PERCEPTION

388.43 IMPAIRMENT OF AUDITORY DISCRIMINATION

388.45 ACQUIRED AUDITORY PROCESSING DISORDER

389.00 UNSPECIFIED CONDUCTIVE HEARING LOSS

389.01 CONDUCTIVE HEARING LOSS, EXTERNAL EAR

389.02 CONDUCTIVE HEARING LOSS, TYMPANIC MEMBRANE

389.03 CONDUCTIVE HEARING LOSS, MIDDLE EAR

389.04 CONDUCTIVE HEARING LOSS, INNER EAR

389.05 CONDUCTIVE HEARING LOSS, UNILATERAL

389.06 CONDUCTIVE HEARING LOSS, BILATERAL

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 11

ICD-9-CM

Diagnosis

Code*

Description

389.08 CONDUCTIVE HEARING LOSS OF COMBINED TYPES

389.10 UNSPECIFIED SENSORINEURAL HEARING LOSS

389.11 SENSORY HEARING LOSS, BILATERAL

389.12 NEURAL HEARING LOSS, BILATERAL

389.13 NEURAL HEARING LOSS, UNILATERAL

389.14 CENTRAL HEARING LOSS

389.17 SENSORY HEARING LOSS, UNILATERAL

389.18 SENSORINEURAL HEARING LOSS, BILATERAL

389.20 MIXED HEARING LOSS, UNSPECIFIED

389.21 MIXED HEARING LOSS, UNILATERAL

389.22 MIXED HEARING LOSS, BILATERAL

430. SUBARACHNOID HEMORRHAGE

431. INTRACEREBRAL HEMORRHAGE

432.0 –

432.9 NONTRAUMATIC EXTRADURAL HEMORRHAGE

434.91 UNSPECIFIED CEREBRAL ARTERY OCCLUSION WITH CEREBRAL

INFARCTION

435.9 UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA

436. ACUTE, BUT ILL-DEFINED, CEREBROVASCULAR DISEASE

437.0 CEREBRAL ATHEROSCLEROSIS

438.0 COGNITIVE DEFICITS DUE TO CEREBROVASCULAR DISEASE

438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE

438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE

438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE

438.10 UNSPECIFIED SPEECH AND LANGUAGE DEFICIT DUE TO

CEREBROVASCULAR DISEASE

438.11 APHASIA DUE TO CEREBROVASCULAR DISEASE

438.12 DYSPHASIA DUE TO CEREBROVASCULAR DISEASE

438.19 OTHER SPEECH AND LANGUAGE DEFICITS DUE TO CEREBROVASCULAR

DISEASE

438.20 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE DUE TO CEREBROVASCULAR

DISEASE

438.50 –

438.53

OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE DUE TO

CEREBROVASCULAR DISEASE

438.81 APRAXIA DUE TO CEREBROVASCULAR DISEASE

438.82 DYSPHAGIA DUE TO CEREBROVASCULAR DISEASE

438.83 FACIAL WEAKNESS AS LATE EFFECT OF CEREBROVASCULAR DISEASE

438.89 OTHER LATE EFFECTS OF CEREBROVASCULAR DISEASE

438.9 UNSPECIFIED LATE EFFECTS OF CEREBROVASCULAR DISEASE DUE TO

CEREBROVASCULAR DISEASE

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 12

ICD-9-CM

Diagnosis

Code*

Description

464.00 ACUTE LARYNGITIS, WITHOUT MENTION OF OBSTRUCTION

476.0 CHRONIC LARYNGITIS

478.30 UNSPECIFIED PARALYSIS OF VOCAL CORDS OR LARYNX

478.31 UNILATERAL PARTIAL PARALYSIS OF VOCAL CORDS OR LARYNX

478.32 UNILATERAL COMPLETE PARALYSIS OF VOCAL CORDS OR LARYNX

478.33 BILATERAL PARTIAL PARALYSIS OF VOCAL CORDS OR LARYNX

478.34 BILATERAL COMPLETE PARALYSIS OF VOCAL CORDS OR LARYNX

478.4 POLYP OF VOCAL CORD OR LARYNX

478.5 OTHER DISEASES OF VOCAL CORDS

478.6 EDEMA OF LARYNX

478.70 –

478.79 UNSPECIFIED DISEASE OF LARYNX

478.9 OTHER AND UNSPECIFIED DISEASES OF UPPER RESPIRATORY TRACT

524.00 –

524.9 UNSPECIFIED MAJOR ANOMALY OF JAW SIZE

528.00 –

528.9 STOMATITIS AND MUCOSITIS, UNSPECIFIED

740.0 ANENCEPHALUS

742.0 ENCEPHALOCELE

742.3 CONGENITAL HYDROCEPHALUS

742.4 OTHER SPECIFIED CONGENITAL ANOMALIES OF BRAIN

742.9 UNSPECIFIED CONGENITAL ANOMALY OF BRAIN, SPINAL CORD, AND

NERVOUS SYSTEM

744.00 –

744.09

UNSPECIFIED CONGENITAL ANOMALY OF EAR CAUSING IMPAIRMENT OF

HEARING

748.2 CONGENITAL WEB OF LARYNX

748.3 OTHER CONGENITAL ANOMALY OF LARYNX, TRACHEA, AND BRONCHUS

748.8 OTHER SPECIFIED CONGENITAL ANOMALY OF RESPIRATORY SYSTEM

749.00-

749.04 UNSPECIFIED CLEFT PALATE CODE RANGE

749.10-

749.14 CLEFT LIP CODE RANGE

749.20-

749.25 CLEFT PALATE WITH CLEFT LIP CODE RANGE

750.0 TONGUE TIE

750.3 CONGENITAL TRACHEOESOPHAGEAL FISTULA, ESOPHAGEAL ATRESIA

AND STENOSIS

750.4 OTHER SPECIFIED CONGENITAL ANOMALY OF ESOPHAGUS

750.9 UNSPECIFIED CONGENITAL ANOMALY OF UPPER ALIMENTARY TRACT

754.0 CONGENITAL MUSCULOSKELETAL DEFORMITIES OF SKULL, FACE, AND

JAW

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 13

ICD-9-CM

Diagnosis

Code*

Description

756.0 CONGENITAL ANOMALIES OF SKULL AND FACE BONES

758.0 DOWN'S SYNDROME

759.89 OTHER SPECIFIED MULTIPLE CONGENITAL ANOMALIES, SO DESCRIBED

767.0 SUBDURAL AND CEREBRAL HEMORRHAGE, BIRTH TRAUMA

767.3 OTHER INJURIES TO SKELETON, BIRTH TRAUMA

781.8 NEUROLOGICAL NEGLECT SYNDROME

783.42 DELAYED MILESTONES

784.3 APHASIA

784.40 VOICE AND RESONANCE DISORDER, UNSPECIFIED

784.41 APHONIA

784.42 DYSPHONIA

784.43 HYPERNASALITY

784.44 HYPONASALITY

784.49 OTHER VOICE AND RESONANCE DISORDERS

784.51 DYSARTHRIA

784.52 FLUENCY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE

784.59 OTHER SPEECH DISTURBANCE

784.60 SYMBOLIC DYSFUNCTION, UNSPECIFIED

784.61 ALEXIA AND DYSLEXIA

784.69 OTHER SYMBOLIC DYSFUNCTION

787.20-

787.24 DYSPHAGIA, CODE RANGE

787.29 DYSPHAGIA, OTHER

799.52 COGNITIVE COMMUNICATION DEFICIT

803.00 OTHER CLOSED SKULL FRACTURE WITHOUT MENTION OF

INTRACRANIAL INJURY, UNSPECIFIED STATE OF CONSCIOUSNESS

804.00 CLOS FXS INVOLV SKL/FCE W/OTH BNS NO ICI UNS SOC

850.0 CONCUSSION WITH NO LOSS OF CONSCIOUSNESS

851.00 CORTEX (CEREBRAL) CONTUSION WITHOUT MENTION OF OPEN

INTRACRANIAL WOUND, STATE OF CONSCIOUSNESS UNSPECIFIED

852.00 –

852.59

SUBARACHNOID HEMORRHAGE FOLLOWING INJURY, WITHOUT MENTION

OF OPEN INTRACRANIAL WOUND, UNSPECIFIED STATE OF

CONSCIOUSNESS

853.00 –

853.19 OTH&UNS ICH FOLLOW INJR W/O OPEN ICW UNS SOC

854.00 –

854.19 ICI OTH&UNS NATR W/O OPEN ICW UNS STATE CONSC

873.70 OPEN WOUND OF MOUTH, UNSPECIFIED SITE, COMPLICATED

874.10 OPEN WOUND OF LARYNX WITH TRACHEA, COMPLICATED

874.11 OPEN WOUND OF LARYNX, COMPLICATED

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 14

ICD-9-CM

Diagnosis

Code*

Description

874.5 OPEN WOUND OF PHARYNX, COMPLICATED

951.8 INJURY TO OTHER SPECIFIED CRANIAL NERVES

959.01 HEAD INJURY, UNSPECIFIED

996.79 OTHER COMPLICATIONS DUE TO OTHER INTERNAL PROSTHETIC DEVICE,

IMPLANT, AND GRAFT

V10.01 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF TONGUE

V10.02 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER AND

UNSPECIFIED PARTS OF ORAL CAVITY AND PHARYNX

V10.21 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARYNX

V10.85 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BRAIN

V12.40 UNSPECIFIED DISORER OF NERVOUS SYSTEM AND SENSE ORGANS

V40.1 PROBLEMS WITH COMMUNICATION (INCLUDING SPEECH)

V41.2 PROBLEMS WITH HEARING

V41.3 OTHER EAR PROBLEMS

V41.4 PROBLEMS WITH VOICE PRODUCTION

V43.81 LARYNX REPLACED BY OTHER MEANS

V45.89 OTHER POSTPROCEDURAL STATUS

V52.8 FITTING AND ADJUSTMENT OF OTHER SPECIFIED PROSTHETIC DEVICE

The following ICD-10 diagnosis codes will be effective October 1, 2014:

ICD-10-CM

Diagnosis

Code* Description

F84.0-F84.9 Pervasive developmental disorders code range (includes infant autism, etc.)

*If applicable, please see Medicare LCD or NCD for additional covered diagnoses.

Not Medically Necessary; therefore not covered:

CPT Codes® 92620 92621 97533

IX. REFERENCES TOP

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 15

American Academy of Pediatrics (AAP), Committee on Children with Disabilities Auditory

integration training and facilitated communication for autism Pediatrics 1998; 102(2):431-

433 Reaffirmed February 1, 2010.

American Speech-Language-Hearing Association Aphasia [Website]: http://www.asha.org.

Accessed May 1, 2014.

American Speech-La 1nguage-Hearing Association (2005) (Central) Auditory Processing

Disorders [Working Group] Website: http://www.asha.org Accessed May 1, 2014.

American Speech-Language Hearing Association. Position Statement. (Central) Auditory

Processing Disorders—The Role of the Audiologist. 2005. [Website]:

http://www.phon.ucl.ac.uk/courses/spsci/audper/ASHA%202005%20CAPD%20statement.pdf

Accessed May 1, 2014.

American Speech-Language-Hearing Association Speech and language development

[Website]: http://www.asha.org/public/speech/development/. Accessed May 1, 2014.

American Speech-Language-Hearing Association Speech and language disorders [Website]:

http://www.asha.org/public/speech/disorders/ Accessed May 1, 2014.

American Speech-Language-Hearing Association Swallowing disorders in adults Website]:

http://www.asha.org/public/speech/swallowing/SwallowingAdults.htm Accessed May 1,

2014.

American Speech-Language-Hearing Association Swallowing disorders in children [Website]:

2014.http://www.asha.org/public/speech/swallowing/FeedSwallowChildren.htm

Accessed May 1, 2014.

Carnaby-Mann, GD, Crary, MA Examining the evidence on neuromuscular electrical

stimulation for swallowing: a meta-analysis Arch Otolaryngol Head Neck Surg. 2007;

133(6):564-571.

Carter, J, M usher, K. Etiology of speech and language disorders in children. In: UpToDate

Online Journal [serial online]: updated July 1, 2013 [Website] : www.uptodate.com .

Accessed May 1, 2014.

Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual

Publication 100-2. Chapter 15, Section 220. Covered Medical and Other Health Services

Effective 08/11/2005. [Website]: http://www.cms.gov Accessed May 1, 2014.

Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual

Publication 100-2. Chapter 15, Section 80.3. Covered Medical and Other Health Services,

Audiological Diagnostic Testing. Effective 04/01/2008. [Website]: http://www.cms.gov

Accessed May 1, 2014.

Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD)

170.3 Speech-Language Pathology Services for the Treatment of Dysphagia. Effective

10/01/06. CMS [Website]: http://www.cms.hhs.gov. Accessed May 1, 2014.

Children’s Speech Care Center. Glossary of Speech and Language Related Terms. [Website]:

http://www.childspeech.net/glossary.html. Accessed May 1, 2014.

El Dib RP, Atallah AN. Evidence-based speech, language and hearing therapy and the

Cochrane Library's systematic reviews. Sao Paulo Med J. 2006 Mar 2; 124(2):51-4.

Jordan, Lori C; Hillis, Argye E Disorders of speech and language: aphasia, apraxia and

dysarthria. Current Opinion in Neurology 19(6):580-585, December 2006.

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 16

May-Benson TA, Koomar JA Systematic review of the research evidence examining the

effectiveness of interventions sensory integrative approach for children. Am J Occupat Ther

2010; 64(3):403-14

Moore, D, Ferguson, M. et al. Nature of Auditory Processing Disorder in Children. Pediatrics

Vol. 126 No. 2 August 2010, [Website]: http://pediatrics.aappublications.org Accessed May

1, 2014.

National Dissemination Center for Children with Disabilities. Information on speech and

language impairments. [Website]: http://www.kidsource.com/NICHCY/index.html Accessed

May 1, 2014.

National Institute of Neurological Disorders and Stroke. Information on Aphasia. [Website]:

http://www.ninds.nih.gov/disorders/aphasia/aphasia.htm Accessed May 1, 2014.

National Institute on Deafness and other Communicative Disorders. Information on Aphasia.

[Website]: http://www.nidcd.nih.gov/health/voice/aphasia.html Accessed. May 1, 2014.

National Institute on Deafness and other Communicative Disorders. Information on Apraxia.

[Website]: http://www.nidcd.nih.gov/health/voice/pages/apraxia.aspx

Accessed May 1, 2014.

Novitas Solutions, Inc. Local Coverage Determination (LCD) L27531: Speech-Language

Pathology (SLP) Services: Communication Disorders. Effective 01/01/14 Accessed May 1,

2014.

Novitas Solutions Inc. Local Coverage Determination (LCD) L27537: Treatment of Dysphagia

(Swallowing Disorders), General; Includes VitalStim Therapy. Effective 04/02/2012.

Accessed May 1, 2014.

Nelson HD, Nygren P, Walker M, Panoscha R. Screening for speech and language delay in

preschool children: systematic evidence review for the US Preventive Services Task Force.

Pediatrics. 2006; 117(2).

Prathanee B, Thinkhamrop B, Dechongkit S. Factors associated with specific language

impairment and later language development during early life: a literature review. Clin

Pediatr (Phila). 2007 Jan; 46(1):22-9. Review.

Smith Hammond, CA, Goldstein, LB. Cough and aspiration of food and liquids due to oral-

pharyngeal dysphagia: ACCP evidence-based clinical practice guidelines. Chest. 2006;

129(1 Suppl): 154S-168S.

Stiegler LN Discovering communicative competencies in a nonspeaking child with autism. Lang

Speech Hear Serv Sch. 2007 Oct; 38(4):400-13.

VitalStim. What is VitalStim? [Website]:http://www.vitalstim.com Accessed May 1, 2014.

West C, et al. Interventions for apraxia of speech following stroke. The Cochrane Database of

Systematic Reviews Issue 4 2005 Oct 19. Edited published in Issue 1, 2009

X. POLICY HISTORY TOP

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 17

MP 8.002

CAC 5/24/04

CAC 10/25/05

CAC 10/31/06

CAC 1/29/08

CAC 11/25/08

7/1/09 Cross-Reference for Pervasive Developmental Disorders

CAC 11/24/09 Consensus review. No change in policy statement, references updated.

4/21/10 Revised exclusion language for central auditory processing

7/19/10 Revised Medicare variation

CAC 11/30/10 Consensus

CAC 4/26/2011 Minor Revision. Central Auditory processing changed from not

medically necessary to investigational. Sensory integration therapy information extracted

and separate policy for this therapy developed. See MP-8.011 Sensory Integration

Therapy

CAC 6/26/12 Consensus. No change in policy statement, references updated.

7/26/13 Admin coding review complete--rsb

CAC 9/24/13 Consensus. No change to policy statements.

CAC 5/20/14 Minor. Removed Auditory processing delay from list of not

medically necessary conditions. Is listed as investigational. References reviewed

and updated. Added rationale section for central auditory processing.

Codes reviewed.

MEDICAL POLICY

POLICY TITLE SPEECH THERAPY (OUTPATIENT)

POLICY NUMBER MP- 8.002

Page 18

Top

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance

Company®, Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the

BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs

and provider relations for all companies.