Speech Therapy

Policy ID: V-16-041

Effective Date: July 01, 2019

Revised Date: May 14, 2025

Revision Effective Date: July 07, 2025

Last Reviewed: May 13, 2025

Applies To: Commercial and Medicaid Expansion

Description

Speech therapy is the treatment of communication impairment and swallowing disorders (dysphagia). Speech therapy services involve the use of special techniques to facilitate the development and maintenance of human verbal communication and swallowing through individual assessment, diagnosis, and rehabilitation.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Speech therapy services may be considered medically necessary when ordered by a physician and performed by a licensed speech pathologist/therapist. Speech therapy services must be directed to the active treatment of at least ONE of the following conditions:

Primary disorder of speech or hearing related organs, e.g., congenital malformations such as cleft lip/palate, or craniofacial disorders, (this is not an all-inclusive list).
Secondary disorder impacting speech or hearing, e.g., chronic ear infections, post-stroke, vocal cord lesions or trauma, (this is not an all-inclusive list).

Voice therapy may be considered medically necessary for ANY of the following conditions (this is not an all-inclusive list):

Closed head trauma; or
Laryngeal trauma and trauma related dysphonia's; or
Polyps; or
Vocal Cord Lesions; or
Vocal Cord Paralysis Or Paresis; or
Vocal Cysts; or
Vocal nodules.

NOTE: Voice therapy provided prior to surgery is not a covered service.

Speech therapy services must achieve a specific diagnosis-related goal for a individual who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time. These services must also provide specific, effective, and reasonable treatment for the individual's diagnosis and physical condition.

Speech therapy should be provided in accordance with an ongoing, written therapy plan.

NOTE: Neuromuscular electrical stimulation where a small current is passed through external electrodes placed on the neck to stimulate inactive or atrophied swallowing muscles may be considered medically necessary as an adjunct to treatment techniques and exercises.

Procedure Codes

92507

92508

92521

92522

92523

92524

92526

92597

92607

92608

92609

92610

92611

96105

96125

97032

97129

97130

97799

G0153

G0161

S9128

S9152

Habilitative Therapy

Speech Therapy services ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury. This also includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.

The treatment plan should be maintained in the medical record and include the following:

Specific statements of long- and short-term goals; and
Measurable objectives; and
A reasonable estimate of when the goals of therapy will be reached; and
A description of the specific treatment techniques and/or exercises to be used in the treatment; and
The frequency and duration of the treatment.

The following services are not covered:

Therapy provided in an in-patient setting if speech therapy was the sole reason for the hospitalization; and
Therapy that is considered primarily educational; and
Services that do not require the skills of a qualified provider of speech therapy including those that can be effectively provided by the individual, family, or caregivers as well as those treatments that maintain function using routine, repetitious, and/or reinforced procedures that are neither diagnostic nor therapeutic (e.g., practicing word drills for developmental articulation errors); and
Speech therapy services for dysfunctions that are self-correcting, such as language therapy for young children with natural dysfluency or developmental articulation errors that may be self-correcting; and
Services that duplicate those provided by physical or occupational therapists. (Therapists should provide different treatments that reflect each therapy discipline's unique perspective on the individual's impairments and functional deficits and not duplicate the same treatment. They must also have separate evaluations, treatment plans, and goals).

NOTE: Speech Therapy Services are not covered to the extent that the services are or can be provided under the laws of any state or political subdivision (e.g., schools).

Procedure Codes

92507

92508

92521

92522

92523

92524

92526

92597

92607

92608

92609

92610

92611

92630

92633

96105

96125

97032

97129

97130

97550

97551

97552

97799

G0153

G0161

S9128

S9152

Maintenance Therapy

Speech Therapy services performed repetitively to maintain a level of function is not eligible for payment unless the member has Habilitative Services benefits. A maintenance program consists of activities that preserve the individual's present level of function and prevent regression of that function. These services generally would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Maintenance therapy (physical or manipulative therapy performed for maintenance rather than restoration), is not eligible for payment.

Procedure Code

S8990

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 92507, 92508, 92521, 92522, 92523, 92524, 92630, 92633, 96125, G0153, G0161, S9128, S9152

F80.0

F80.1

F80.2

F80.4

F80.81

F80.82

F80.89

F80.9

F84.0

F84.2

F84.3

F84.5

F84.8

F84.9

G93.40

G93.41

G93.49

H93.25

I67.83

I69.023

I69.123

I69.223

I69.320

I69.323

I69.823

I69.923

J38.00

J38.01

J38.02

J38.1

J38.2

J38.3

J38.7

K11.7

Q35.1

Q35.3

Q35.5

Q35.7

Q35.9

Q36.0

Q36.1

Q36.9

Q37.0

Q37.1

Q37.2

Q37.3

Q37.4

Q37.5

Q37.8

Q37.9

Q38.1

Q38.5

Q38.8

R06.00

R06.09

R06.3

R06.83

R06.89

R13.0

R13.10

R13.11

R13.12

R13.13

R13.14

R13.19

R47.01

R47.02

R47.1

R47.81

R47.82

R47.89

R48.1

R48.2

R48.8

R48.9

R49.0

R49.1

R49.21

R49.22

R49.8

R49.9

R63.31

R63.32

R68.2

S06.0X0A

S06.0X1A

S06.0X5A

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020

Updated language, and
Added additional Procedure Codes.

Internal Medical Policy Committee 5-19-2020

Coding Update for VitalStim

Internal Medical Policy Committee 5-20-2021 Annual Review

Internal Medical Policy Committee 11-23-2021 Revision and coding update Effective January 01, 2022

Added Diagnosis Codes: F84.0; F84.2; F84.3; F84.5; F84.8; F84.9; R63.31; and R63.32

Internal Medical Policy Committee 07-21-2022 Revision of criteria with coding update- Effective September 05, 2022

Added Procedure Code: 97032

Internal Medical Policy Committee 9-12-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 5-14-2024 Coding update - Effective July 01, 2024

Added procedure codes 92526; 92597; 92607; 92608; 92609; 92610; 92611; 96105; 96125; 97032; 97129; 97130; & 97799; and
Added Policy Application; and
Added statement 'Coverage is subject to the specific terms of the member's benefit plan'.

Internal Medical Policy Committee 7-16-2024 Coding update- Effective September 02, 2024

Added Procedure Codes 97550; 97551; and 97552 in Habilitative section.

Internal Medical Policy Committee May 13, 2025- Annual Review-no changes in criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: V-16-040

Effective Date: July 01, 2019

Revised Date: July 20, 2024

Revision Effective Date: September 02, 2024

Last Reviewed: July 16, 2024

Archived Date: July 06, 2025

Applies To: Commercial and Medicaid Expansion

Description

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Primary disorder of speech or hearing related organs, e.g., congenital malformations such as cleft lip/palate, or craniofacial disorders, (this is not an all-inclusive list).
Secondary disorder impacting speech or hearing, e.g., chronic ear infections, post-stroke, vocal cord lesions or trauma, (this is not an all-inclusive list).

Voice therapy may be considered medically necessary for ANY of the following conditions (this is not an all-inclusive list):

Closed head trauma; or
Laryngeal trauma and trauma related dysphonia's; or
Polyps; or
Vocal Cord Lesions; or
Vocal Cord Paralysis Or Paresis; or
Vocal Cysts; or
Vocal nodules.

NOTE: Voice therapy provided prior to surgery is not a covered service.

Speech therapy should be provided in accordance with an ongoing, written therapy plan.

Procedure Codes

92507

92508

92521

92522

92523

92524

92526

92597

92607

92608

92609

92610

92611

96105

96125

97032

97129

97130

97799

G0153

G0161

S9128

S9152

Habilitative Therapy

The treatment plan should be maintained in the medical record and include the following:

Specific statements of long- and short-term goals; and
Measurable objectives; and
A reasonable estimate of when the goals of therapy will be reached; and
A description of the specific treatment techniques and/or exercises to be used in the treatment; and
The frequency and duration of the treatment.

The following services are not covered:

Therapy provided in an in-patient setting if speech therapy was the sole reason for the hospitalization; and
Therapy that is considered primarily educational; and
Services that do not require the skills of a qualified provider of speech therapy including those that can be effectively provided by the individual, family, or caregivers as well as those treatments that maintain function using routine, repetitious, and/or reinforced procedures that are neither diagnostic nor therapeutic (e.g., practicing word drills for developmental articulation errors); and
Speech therapy services for dysfunctions that are self-correcting, such as language therapy for young children with natural dysfluency or developmental articulation errors that may be self-correcting; and
Services that duplicate those provided by physical or occupational therapists. (Therapists should provide different treatments that reflect each therapy discipline's unique perspective on the individual's impairments and functional deficits and not duplicate the same treatment. They must also have separate evaluations, treatment plans, and goals).

NOTE: Speech Therapy Services are not covered to the extent that the services are or can be provided under the laws of any state or political subdivision (e.g., schools).

Procedure Codes

92507

92508

92521

92522

92523

92524

92526

92597

92607

92608

92609

92610

92611

92630

92633

96105

96125

97032

97129

97130

97550

97551

97552

97799

G0153

G0161

S9128

S9152

Maintenance Therapy

Procedure Code

S8990

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 92507, 92508, 92521, 92522, 92523, 92524, 92630, 92633, 96125, G0153, G0161, S9128, S9152

F80.0

F80.1

F80.2

F80.4

F80.81

F80.82

F80.89

F80.9

F84.0

F84.2

F84.3

F84.5

F84.8

F84.9

G93.40

G93.41

G93.49

H93.25

I67.83

I69.023

I69.123

I69.223

I69.320

I69.323

I69.823

I69.923

J38.00

J38.01

J38.02

J38.1

J38.2

J38.3

J38.7

K11.7

Q35.1

Q35.3

Q35.5

Q35.7

Q35.9

Q36.0

Q36.1

Q36.9

Q37.0

Q37.1

Q37.2

Q37.3

Q37.4

Q37.5

Q37.8

Q37.9

Q38.1

Q38.5

Q38.8

R06.00

R06.09

R06.3

R06.83

R06.89

R13.0

R13.10

R13.11

R13.12

R13.13

R13.14

R13.19

R47.01

R47.02

R47.1

R47.81

R47.82

R47.89

R48.1

R48.2

R48.8

R48.9

R49.0

R49.1

R49.21

R49.22

R49.8

R49.9

R63.31

R63.32

R68.2

S06.0X0A

S06.0X1A

S06.0X5A

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020

Updated language, and
Added additional procedure codes.

Internal Medical Policy Committee 5-19-2020

Coding Update for VitalStim

Internal Medical Policy Committee 5-20-2021 Annual Review

Internal Medical Policy Committee 11-23-2021 Revision and coding update Effective January 01, 2022

Added diagnosis codes: F84.0; F84.2; F84.3; F84.5; F84.8; F84.9; R63.31; and R63.32

Internal Medical Policy Committee 07-21-2022 Revision of criteria with coding update- Effective September 05, 2022

Added procedure code: 97032

Internal Medical Policy Committee 9-12-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 5-14-2024 Coding update - Effective July 01, 2024

Added procedure codes 92526; 92597; 92607; 92608; 92609; 92610; 92611; 96105; 96125; 97032; 97129; 97130; & 97799; and
Added Policy Application; and
Added statement 'Coverage is subject to the specific terms of the member's benefit plan'.

Internal Medical Policy Committee 7-16-2024 Coding update- Effective September 02, 2024

Added procedure codes 97550; 97551; and 97552 in Habilitative section.

Medical Policies Quick Search

Speech Therapy

Description

Policy Application

Criteria

Procedure Codes

Habilitative Therapy

Procedure Codes

Maintenance Therapy

Procedure Code

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Procedure Codes

Habilitative Therapy

Procedure Codes

Maintenance Therapy

Procedure Code

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer