Subject:
Speech Therapy in the Home and Outpatient Facility
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Speech therapy is the evaluation and treatment of language, speech articulation and swallowing dysfunction.
Rehabilitation is the process of evaluation, treatment and education for the purpose of restoring or returning, as near as possible, to the skills and level of function that the individual possessed prior to illness, disease, injury or therapeutic intervention.
Habilitation is the process of evaluation, treatment and education for the purpose of developing skills and function which the individual has not previously possessed.
Maintenance is the point at which no further improvement in restoration of function, reduction in disability or relief of pain is expected. Continuation of therapy at this point would be for the purpose of holding at a steady state or preventing deterioration.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
I. For Members or Covered Persons in benefit plans that are subject to the New Jersey Autism and Developmental Disabilities mandate (effective 02/08/2010) and for ASO/ASC/Self-Insured/Self-Funded Groups which have opted to adopt the New Jersey Autism and Developmental Disabilities mandate:
A. Speech therapy in the home or outpatient setting is eligible for coverage when:
1. the member has a primary diagnosis of autism or another developmental disability, and
[Note: For purposes of this mandate, a Developmental Disability is defined as a severe, chronic disability that:
a) is attributable to a mental or physical impairment or a combination of mental and physical impairments;
b) is manifested before the Member or Covered Person:
1. attains age 22 for purposes of the Diagnosis and Treatment of Autism and Other Developmental Disabilities provision; or
2. attains age 26 for all other provisions;
c) is likely to continue indefinitely;
d) results in substantial functional limitations in three or more of the following areas of major life activity: self-care; receptive and expressive language; learning; mobility; self-direction; capacity for independent living; economic self-sufficiency;
e) reflects the Member or Covered Person’s need for a combination and sequence of special interdisciplinary or generic care, treatment or other services which are of lifelong or of extended duration and are individually planned and coordinated.
Developmental disability includes but is not limited to severe disabilities attributable to mental retardation, autism, cerebral palsy, epilepsy, spina-bifida and other neurological impairments where the above criteria are met.]
2. the therapy is prescribed via a treatment plan which must include, but are not limited, to the following:
a. a diagnosis,
b. the proposed treatment by type, frequency, and duration,
c. the anticipated outcomes stated as goals,
d. the frequency schedule by which the treatment plan will be updated, and
e. the treating physician's signature
B. Continued medical necessity of speech therapy for the treatment of autism or another developmental disability will be determined upon review of progress notes and an updated treatment plan. The progress notes must indicate:
- continued improvement within the past treatment period as defined by the prior treatment plan,
- that there is an expectation that continued therapy will result in measurable improvement within a reasonable and predictable period of time based on the updated treatment plan,
- that the member is actively participating in treatment sessions, and
- that generalization and carry-over of targeted skills into natural environment is occurring.
[INFORMATIONAL NOTE: According to the New Jersey Autism and Disabilities mandate:
- Coverage required for therapies and interventions may be subject to utilization review, including periodic review, to determine the continued medical necessity of the specified therapies and interventions.
- An updated treatment plan may only be requested once every six months from the treating physician to review medical necessity, unless Horizon BCBSNJ and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.]
- Benefits for covered therapies and interventions cannot be denied on the basis that they are not restorative.]
C. Speech therapy for the treatment of autism or another developmental disability cannot be denied on the basis that it is not restorative.
D. Maintenance therapy is not considered medically necessary.
II. For Members or Covered Persons in benefit plans that are subject to the New Jersey Autism and Developmental Disabilities mandate (effective 02/08/2010) who seek Speech Therapy treatment for a diagnosis other than autism or another developmental disability
for ASO/ASC/Self-Insured/Self-Funded Groups which have opted to adopt the New Jersey Autism and Developmental Disabilities mandate who seek Speech Therapy treatment for a diagnosis other than autism or another developmental disability
for benefit plans that are not subject to the New Jersey Autism and Developmental Disabilities mandate and for ASO/ASC/Self-Insured/Self-Funded Groups which have opted NOT to adopt the New Jersey Autism and Developmental Disabilities mandate, the following statements apply:
A. Contract limitations for speech therapy services in the home or outpatient setting supercede this policy and will determine the available benefit. Reimbursable benefit is determined by establishing medical necessity and appropriateness, subject to periodic review.
B. Speech therapy services in the home or outpatient setting must be ordered by a physician and performed by a licensed speech therapist (also known as speech-language pathologist, speech pathologist or speech clinician) or an appropriately trained physician.
C. Medical record documentation (i.e., copies of original medical records submitted either hard copy or electronically) must be provided to determine medical necessity.
D. Speech therapy services in the home or outpatient setting, whether for rehabilitation or habilitation purposes, are considered medically necessary for the following conditions:
1. communication or swallowing disorder
2. loss or impairment of speech
Generally, there is an expectation that there will be measurable improvement within a reasonable and predictable period of time.
E. Maintenance therapy is not considered medically necessary.
F. There must be a therapeutic plan developed by the provider containing the following components:
1. The diagnosis responsible for the speech, language or swallowing disorder.
2. The specific goals and objectives that will be used to quantitate improvement.
3. The specific treatment techniques or modalities to be used in achieving the goals and objectives.
4. The specific time frame and number of visits in which the goals and objectives will be achieved.
G. Speech therapy in the home setting requires the member to meet homebound criteria. An individual shall be considered "confined to home" (homebound) when both criteria are met:
1. The member must either:
- because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence; or
- have a condition such that leaving his or her home is medically contraindicated.
And
2. There must exist a normal inability to leave home and leaving home must require a considerable and taxing effort.
H. Continued medical necessity of speech therapy will be determined upon review of progress notes and an updated treatment plan submitted either hard copy or electronically. The progress notes must indicate:
- continued improvement within the past treatment period as defined by the prior treatment plan;
- that there is an expectation that continued therapy will result in measurable improvement within a reasonable and predictable period of time based on the updated treatment plan;
- that the member is actively participating in treatment sessions; and
- that generalization and carry-over of targeted skills into natural environment is occurring.
I. Duplicate or concurrent speech therapy in the home or outpatient setting provided by multiple providers is not medically necessary. [EXCEPTION: Speech therapy received through the educational or school system is not considered duplicate therapy when a member is concurrently receiving speech therapy covered by his/her Horizon health coverage.]
Medicare Coverage:
Medicare Advantage Products differ with the Horizon BCBCNJ Medical Policy.
Maintenance Therapy
A maintenance program consists of activities that preserve the patient's present level of function or prevent regression of that function. Maintenance therapy is covered when treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.
There are multiple NCD and LCD applicable to speech therapy services. For eligibility and coverage, refer to the following:
National Coverage Determination (NCD) for Speech-Language Pathology Services for the Treatment of Dysphagia (170.3). Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?ncdid=192&ver=2.
National Coverage Determination (NCD) for Melodic Intonation Therapy (170.2). Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?ncdid=89&ver=1.
Local Coverage Determination (LCD): Speech - Language Pathology (SLP) Services: Communication Disorders (L35070). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35070&ver=61&DocID=L35070&bc=KAAAABgAAAAA&.
Medicaid Coverage:
FIDE-SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Speech Therapy in the Home and Outpatient Facility
Speech Therapy
Therapy, Speech
References:
1. New Jersey Autism and Developmental Disabilities mandate. # A-2238. Effective 02/8/21010.
2. Kent RD. Research on speech motor control and its disorders: a review and prospective. J Commun Disord 2000 Sep-Oct;33(5):391-427.
3. Yairi E, Ambrose N, Cox N. Genetics of stuttering: A critical review. J Speech Hear Res 1996 Aug;39(4):771-784.
4. Foundas Al, Bollich AM, Corey DM, et al. Anomalous anatomy of speech-language areas in adults with persistent developmental stuttering. Neurology 2001 Jul;57(2):207-215.
5. Fox PT, Ingham RJ, Ingham JC, et al. Brain correlates of stuttering and syllable production. A PET performance-correlation analysis. Brain 2000 Oct;123(Pt 10);1985-2004.
6. Shriberg LD, Aram DM, Kwiatkowski J. Developmental apraxia of speech: I. Descriptive and theoretical perspectives. J Speech Lang Hear Res 1997 Apr;40(2):273-285.
7. Shriberg LD, Aram DM, Kwiatkowski J. Developmental apraxia of speech: III. A subtype marked by inappropriate stress. J Speech Lang Hear Res 1997 Apr;40(2):313-337.
8. Lawrence M, Barclay DM 3rd. Stuttering: a brief review. Am Fam Physician 1998 May;57(9):2175-2178.
9. Costa D, Kroll R. Stuttering: an update for physicians. CMAJ 2000 Jun;162(13):1849-1855.
10. Peters HF, Hulstijn W, Van Liesbout PH. Recent developments in speech motor research into stuttering. Foli Phoniatr Logop 2000 Jan-Jun;52(1-3):103-119.
11. American Speech-Language-Hearing Association (2001) Scope of practice in speech-language pathology. Rockville, MD: Author.
Available at http://www.asha.org/uploadedFiles/SP2007-00283.pdf (accessed 11/12/2013)
12. UpToDate. Evaluation and treatment of speech and language disorders in children. Literature review current through January 2016.
13. UpToDate. Speech and swallowing rehabilitation of the patient with head and neck cancer. Literature review current through January 2016.
14. Carter J, Musher K. Evaluation and treatment of speech and language disorders in children. In UpToDate; Duryea TK, Augustyn M, Torchia MM. (eds) UpToDate, Waldham, MA. (Accessed June 17, 2019).
15. Lewin JS, Teng MS, Kotz T. Speech and swallowing rehabilitation of the patient with head and neck cancer. In UpToDate, Brockstein BE, Fried MP, Shah S, Chen W (eds). UpToDate, Waldham, MA. (Accessed June 17, 2019).
16. Clark DG. Aphasia: Prognosis and treatment. In UpToDate, Mendez MF, Wilterdink JL (eds). UpToDate, Waldham, MA. (Accessed June 17, 2019).
17. Carter J, Musher K. Evaluation and treatment of speech and language disorders in children. In UpToDate; Duryea TK, Augustyn M, Torchia MM. (eds) UpToDate, Waldham, MA. (Accessed June 30, 2020).
18. Lewin JS, Teng MS, Kotz T. Speech and swallowing rehabilitation of the patient with head and neck cancer. In UpToDate, Brockstein BE, Fried MP, Shah S, Chen W (eds). UpToDate, Waldham, MA. (Accessed June 30, 2020).
19. Clark DG. Aphasia: Prognosis and treatment. In UpToDate, Mendez MF, Wilterdink JL (eds). UpToDate, Waldham, MA. (Accessed June 30, 2020).
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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