Aetna Speech Therapy coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• GENERAL CRITERIA (meet ALL of): Speech therapy is considered medically necessary for treating communication disabilities and/or swallowing disorders (dysphagia) from disease when ALL of the following are met: (1) the member's physician has determined the member's condition can improve significantly with speech therapy; (2) the speech therapy is expected to result in a significant improvement in the individual's condition within a reasonable and generally predictable period of time; (3) speech therapy services are performed by a duly licensed and certified (if applicable) provider, with all services within the applicable scope of practice for the provider in their licensed jurisdiction; (4) the services are of the complexity and nature to require that they are performed by a licensed speech-language pathologist or provided under their direct supervision by a licensed ancillary person as permitted under state laws; AND (5) services are provided in accordance with an ongoing, written plan of care that is reviewed with and approved by the treating physician in accordance with applicable state laws and regulations.
• Primary covered indication: Treatment of communication disabilities and/or swallowing disorders (dysphagia) from disease (when the five general criteria above are met).
• Criterion 1 of general criteria: The member's physician has determined that the member's condition can improve significantly with speech therapy.
• Criterion 2 of general criteria: The speech therapy is expected to result in a significant improvement in the individual's condition within a reasonable and generally predictable period of time.
• Criterion 3 of general criteria: Speech therapy services must be performed by a duly licensed and certified, if applicable, provider; all services provided must be within the applicable scope of practice for the provider in their licensed jurisdiction where the services are provided.
• Criterion 4 of general criteria: The speech therapy services provided must be of the complexity and nature to require that they are performed by a licensed speech-language pathologist or provided under their direct supervision by a licensed ancillary person as permitted under state laws.
• Criterion 5 of general criteria: Speech therapy services must be provided in accordance with an ongoing, written plan of care that is reviewed with and approved by the treating physician in accordance with applicable state laws and regulations.
• Idiopathic delays in speech development (meet BOTH of): Speech therapy for idiopathic delays in speech development is covered when (1) the member is 18 months of age or older AND (2) the member has been evaluated by a qualified speech-language therapist who has determined that a treatable communication problem exists.
• Continuation of services: After the initial authorization period, speech therapy may continue to be medically necessary only when none of the discontinuation circumstances apply (i.e., therapeutic goals have not yet been met and functional speech/language deficits remain, measurable improvement in the person's condition continues, the person can consistently participate in speech therapy, and the person's needs do not extend beyond the scope of a speech therapist's competence or scope of practice).

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 92507·PA verdict·Rate
• 92508·PA verdict·Rate
• 92630·PA verdict·Rate
• 92633·PA verdict·Rate

Documentation required

• A written, ongoing plan of care that is reviewed with and approved by the treating physician.
• Plan of care must include the date of onset or exacerbation of the disorder/diagnosis.
• Plan of care must include the speech therapy evaluation.
• Plan of care must include specific statements of long-term and short-term goals that are specific, quantifiable (measurable), and objective.
• Plan of care must include a reasonable estimate of when the goals will be reached.
• Plan of care must include the specific treatment techniques and/or exercises to be used in treatment.
• Plan of care must include the frequency and duration of treatment, which must be medically necessary and consistent with generally accepted standards of practice.
• Plan of care must be signed by the member's attending physician and speech therapist.
• Plan of care must be ongoing (i.e., updated as the member's condition changes) and demonstrate a reasonable expectation of improvement.
• The member should be re-evaluated regularly (i.e., monthly) and the results of these evaluations recorded in a standard format, with documentation of progress made toward the goals of speech therapy.

Frequently asked questions

When does Aetna cover Speech Therapy (CPT 92507), and what gets it denied?

Aetna CPB 0243 covers speech therapy as medically necessary to treat communication disabilities and/or swallowing disorders (dysphagia) from disease when all five gating criteria are met (significant expected improvement in a predictable time, licensed/supervised SLP services, and a written plan of care reviewed and approved by the treating physician); idiopathic speech-development delay is covered only for members 18 months or older who have been evaluated and found to have a treatable communication problem. The policy excludes maintenance/self-correcting/duplicate/non-skilled therapy and deems certain modalities (altered auditory feedback devices, facilitated communication, Orton Gillingham, TENS for voice/swallowing, speech therapy for chronic cough, and speech therapy for post-extubation dysphonia after COVID-19) experimental, investigational, or unproven. The bulletin states no explicit precertification requirement; it notes only that short-term speech therapy in HMO/QPOS plans accumulates toward the 60-day or other applicable rehabilitation benefit limit. Coverage criteria include: GENERAL CRITERIA (meet ALL of): Speech therapy is considered medically necessary for treating communication disabilities and/or swallowing disorders (dysphagia) from disease when ALL of the following are met: (1) the member's physician has determined the member's condition can improve significantly with speech therapy; (2) the speech therapy is expected to result in a significant improvement in the individual's condition within a reasonable and generally predictable period of time; (3) speech therapy services are performed by a duly licensed and certified (if applicable) provider, with all services within the applicable scope of practice for the provider in their licensed jurisdiction; (4) the services are of the complexity and nature to require that they are performed by a licensed speech-language pathologist or provided under their direct supervision by a licensed ancillary person as permitted under state laws; AND (5) services are provided in accordance with an ongoing, written plan of care that is reviewed with and approved by the treating physician in accordance with applicable state laws and regulations.; Primary covered indication: Treatment of communication disabilities and/or swallowing disorders (dysphagia) from disease (when the five general criteria above are met).; Criterion 1 of general criteria: The member's physician has determined that the member's condition can improve significantly with speech therapy.; Criterion 2 of general criteria: The speech therapy is expected to result in a significant improvement in the individual's condition within a reasonable and generally predictable period of time.; Criterion 3 of general criteria: Speech therapy services must be performed by a duly licensed and certified, if applicable, provider; all services provided must be within the applicable scope of practice for the provider in their licensed jurisdiction where the services are provided.; Criterion 4 of general criteria: The speech therapy services provided must be of the complexity and nature to require that they are performed by a licensed speech-language pathologist or provided under their direct supervision by a licensed ancillary person as permitted under state laws.; Criterion 5 of general criteria: Speech therapy services must be provided in accordance with an ongoing, written plan of care that is reviewed with and approved by the treating physician in accordance with applicable state laws and regulations.; Idiopathic delays in speech development (meet BOTH of): Speech therapy for idiopathic delays in speech development is covered when (1) the member is 18 months of age or older AND (2) the member has been evaluated by a qualified speech-language therapist who has determined that a treatable communication problem exists.; Continuation of services: After the initial authorization period, speech therapy may continue to be medically necessary only when none of the discontinuation circumstances apply (i.e., therapeutic goals have not yet been met and functional speech/language deficits remain, measurable improvement in the person's condition continues, the person can consistently participate in speech therapy, and the person's needs do not extend beyond the scope of a speech therapist's competence or scope of practice).. Applies to 4 codes: 92507, 92508, 92630, 92633. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: A written, ongoing plan of care that is reviewed with and approved by the treating physician.; Plan of care must include the date of onset or exacerbation of the disorder/diagnosis.; Plan of care must include the speech therapy evaluation.; Plan of care must include specific statements of long-term and short-term goals that are specific, quantifiable (measurable), and objective.; Plan of care must include a reasonable estimate of when the goals will be reached.; Plan of care must include the specific treatment techniques and/or exercises to be used in treatment.; Plan of care must include the frequency and duration of treatment, which must be medically necessary and consistent with generally accepted standards of practice.; Plan of care must be signed by the member's attending physician and speech therapist.; Plan of care must be ongoing (i.e., updated as the member's condition changes) and demonstrate a reasonable expectation of improvement.; The member should be re-evaluated regularly (i.e., monthly) and the results of these evaluations recorded in a standard format, with documentation of progress made toward the goals of speech therapy. Policy exclusions and limitations: Experimental, investigational, or unproven: Altered auditory feedback devices for stuttering and all other indications, because of a lack of evidence in the peer-reviewed published medical literature on the effectiveness of these devices.; Experimental, investigational, or unproven: Facilitated communication for all indications.; Experimental, investigational, or unproven: Orton Gillingham approach for speech therapy.; Experimental, investigational, or unproven: Speech therapy as a treatment for chronic cough.; Experimental, investigational, or unproven: Speech therapy for post-extubation dysphonia after hospitalization with COVID-19.; Experimental, investigational, or unproven: Transcutaneous electrical nerve stimulation for use in speech therapy rehabilitation of voice and swallowing function.; Experimental, investigational, or unproven (age gate): Speech therapy for idiopathic delays in speech development for infants and children younger than 18 months of age, because idiopathic delays in speech development cannot be reliably diagnosed or treated in the prelingual developmental stage.; Not medically necessary: Duplicate therapy when members receive both occupational, physical and speech therapy; the therapies should provide different treatments and not duplicate the same treatment.; Not medically necessary: Maintenance programs such as drills, techniques, and exercises that are intended to preserve the member's present level of function or prevent regression of function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved and when no further functional progress is apparent or expected to occur (including continued activities for individuals who have achieved generally accepted levels of function and are at a plateau or have reached 'normal' levels).; Not medically necessary: Treatments that do not require the skills of a qualified provider of speech therapy services, such as treatments that maintain function by using routine, repetitious, and reinforced procedures that are neither diagnostic nor therapeutic (e.g., practicing word drills for developmental articulation errors), or procedures that may be carried out effectively by the member, family, or caregivers at home on their own.; Not medically necessary: Speech therapy for dysfunctions that are self-correcting, such as language therapy for young children with natural dysfluency or developmental articulation errors that are self-correcting.; Discontinuation (no longer medically necessary after the initial authorization period if ONE OR MORE present): Therapeutic goals have been met and the person no longer presents with functional speech and/or language deficits.; Discontinuation (no longer medically necessary): There is no measurable improvement in the person's condition.; Discontinuation (no longer medically necessary): The person cannot consistently participate in speech therapy.; Discontinuation (no longer medically necessary): The person's needs (e.g., behavioral needs) extend beyond the scope of a speech therapist's personal competence or scope of practice. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Does Aetna require prior authorization for Speech Therapy?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: A written, ongoing plan of care that is reviewed with and approved by the treating physician.; Plan of care must include the date of onset or exacerbation of the disorder/diagnosis.; Plan of care must include the speech therapy evaluation.; Plan of care must include specific statements of long-term and short-term goals that are specific, quantifiable (measurable), and objective.; Plan of care must include a reasonable estimate of when the goals will be reached.; Plan of care must include the specific treatment techniques and/or exercises to be used in treatment.; Plan of care must include the frequency and duration of treatment, which must be medically necessary and consistent with generally accepted standards of practice.; Plan of care must be signed by the member's attending physician and speech therapist.; Plan of care must be ongoing (i.e., updated as the member's condition changes) and demonstrate a reasonable expectation of improvement.; The member should be re-evaluated regularly (i.e., monthly) and the results of these evaluations recorded in a standard format, with documentation of progress made toward the goals of speech therapy.

What does Aetna exclude for Speech Therapy?

Policy exclusions and limitations: Experimental, investigational, or unproven: Altered auditory feedback devices for stuttering and all other indications, because of a lack of evidence in the peer-reviewed published medical literature on the effectiveness of these devices.; Experimental, investigational, or unproven: Facilitated communication for all indications.; Experimental, investigational, or unproven: Orton Gillingham approach for speech therapy.; Experimental, investigational, or unproven: Speech therapy as a treatment for chronic cough.; Experimental, investigational, or unproven: Speech therapy for post-extubation dysphonia after hospitalization with COVID-19.; Experimental, investigational, or unproven: Transcutaneous electrical nerve stimulation for use in speech therapy rehabilitation of voice and swallowing function.; Experimental, investigational, or unproven (age gate): Speech therapy for idiopathic delays in speech development for infants and children younger than 18 months of age, because idiopathic delays in speech development cannot be reliably diagnosed or treated in the prelingual developmental stage.; Not medically necessary: Duplicate therapy when members receive both occupational, physical and speech therapy; the therapies should provide different treatments and not duplicate the same treatment.; Not medically necessary: Maintenance programs such as drills, techniques, and exercises that are intended to preserve the member's present level of function or prevent regression of function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved and when no further functional progress is apparent or expected to occur (including continued activities for individuals who have achieved generally accepted levels of function and are at a plateau or have reached 'normal' levels).; Not medically necessary: Treatments that do not require the skills of a qualified provider of speech therapy services, such as treatments that maintain function by using routine, repetitious, and reinforced procedures that are neither diagnostic nor therapeutic (e.g., practicing word drills for developmental articulation errors), or procedures that may be carried out effectively by the member, family, or caregivers at home on their own.; Not medically necessary: Speech therapy for dysfunctions that are self-correcting, such as language therapy for young children with natural dysfluency or developmental articulation errors that are self-correcting.; Discontinuation (no longer medically necessary after the initial authorization period if ONE OR MORE present): Therapeutic goals have been met and the person no longer presents with functional speech and/or language deficits.; Discontinuation (no longer medically necessary): There is no measurable improvement in the person's condition.; Discontinuation (no longer medically necessary): The person cannot consistently participate in speech therapy.; Discontinuation (no longer medically necessary): The person's needs (e.g., behavioral needs) extend beyond the scope of a speech therapist's personal competence or scope of practice. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT