CurrentCapital BluecrossPolicy MP 8.002

Speech Therapy (Outpatient)

Governs medical necessity and coverage criteria for outpatient speech therapy and related diagnostic/treatment services for Capital BlueCross members; affects providers delivering speech-language pathology and related interventions.

Policy Summary

PayerCapital Bluecross

PolicySpeech Therapy (Outpatient)

Policy CodePolicy MP 8.002

Change TypeNo material changes

Effective DateDec 1, 2025

Next Review DateJul 31, 2025

Key ActionVerify product-specific prior authorization requirements and document medical necessity, including goals, orders, and prior therapy summaries.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleListed indications

investigational listInvestigational services

detailedDocumentation required

multipleCovered codes

5+Not medically necessary Dx

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Coverage Criteria — When Speech Therapy Is Covered

Medical necessity and covered indications

Covered when ALL of the following are met

General necessity: Services are reasonable and necessary for the treatment of the individual's illness or injury and there is an expectation of significant and measurable improvement in functioning within a reasonable period, with regular documentation of improvement.

From policy general statement

Covered indications: Speech therapy directed to active treatment of at least one listed condition (e.g., autism spectrum disorders; childhood speech delay due to congenital hearing loss or disease; congenital craniofacial anomalies such as cleft palate/lip; disease such as post-cerebrovascular accident; developmental delay; medical/biological voice dysfunctions with vocal cord lesions or movement abnormalities; post-laryngectomy/previous therapeutic interventions such as esophageal training; swallowing disorders including dysphagia; trauma affecting speech centers; pediatric speech and language problems).

Listed examples in policy

Certain services are designated investigational and therefore not covered. Specifically, central auditory processing disorder (CAPD) testing or treatment is considered investigational due to insufficient evidence of benefit. Also listed as investigational is neuromuscular electrical stimulation therapy for dysphagia (e.g., VitalStim®). Additionally, evaluation or treatment solely for attention deficit disorder/attention deficit hyperactivity disorder or for behavioral problems (including impulsive behavior/impulsivity syndrome) is considered investigational unless the individual has a concurrent diagnosis that meets covered indications in this policy. These investigational designations may lead to denial of coverage for the related services.

The policy identifies specific ICD-10-CM diagnosis codes that are considered not medically necessary and therefore not covered. Examples listed include: F63.89 (Other impulse disorders), F90.0 (ADHD, predominantly inattentive type), F90.1 (ADHD, predominantly hyperactive type), F90.2 (ADHD, combined type), and F90.8 (ADHD, other type). Services provided that are linked to these diagnosis codes should be considered noncovered under this policy.

The policy states that maintenance therapy services are considered not covered, with one exception: individuals whose benefits are subject to the terms mandated by Pennsylvania Act 62 of 2008, Section 635.2 (Autism Spectrum Disorders Coverage). For those members, the statutory mandate takes precedence and coverage may apply as specified in the referenced autism policy (MP 2.304).

Speech therapy services specifically associated with the ICD-10-CM codes listed as not medically necessary (for example, F63.89, F90.0, F90.1, F90.2, F90.8) are explicitly identified as not medically necessary and therefore not covered. Additionally, services for attention-deficit disorders or behavioral problems are considered investigational unless a covered concurrent diagnosis exists; such designations constitute explicit exclusions from coverage.

Code Lists and Coverage Status

Investigational CPT/Procedure CodesCPTNot Covered

92620	Procedure code listed as investigational / not covered
92621	Procedure code listed as investigational / not covered

Covered CPT/Procedure and Miscellaneous CodesmixedCovered

92526	Procedure code listed as covered when medically necessary
G0161	Procedure code listed in covered section
S9128	Procedure code listed in covered section
92507	Procedure code listed in covered section
92508	Procedure code listed in covered section
92521	Procedure code listed in covered section
92522	Procedure code listed in covered section
92523	Procedure code listed in covered section
92524	Procedure code listed in covered section
96105	Listed alongside G0161 in covered section

1–10 of 12

1/2

ICD-10-CM Diagnosis Codes considered not medically necessaryICD-10Not Covered

F63.89	Other impulse disorders — listed as not medically necessary
F90.0	Attention-deficit hyperactivity disorder, predominantly inattentive type — listed as not medically necessary
F90.1	Attention-deficit hyperactivity disorder, predominantly hyperactive type — listed as not medically necessary
F90.2	Attention-deficit hyperactivity disorder, combined type — listed as not medically necessary
F90.8	Attention-deficit hyperactivity disorder, other type — listed as not medically necessary

Provider Responsibilities, Documentation, and Prior Authorization

Prior Authorization

Product variation / Prior Authorization Note

This policy applies to specific Capital Blue Cross products and programs; coverage, prior authorization, and benefit variations may differ by product. Verify product-specific prior authorization requirements and plan restrictions before scheduling services.

FEP PPO: Refer to FEP Medical Policy Manual: https://www.fepblue.org/benefit-plans/medical-policies-and-utilization-managementguidelines/medical-policies

Note

Coverage Determined by Benefit Plan

Coverage and payment are determined by the member's benefit program and eligibility on the date of service. Confirm member benefits, eligibility, and whether speech therapy services are a covered benefit under the member's specific plan prior to providing services.

Final claim payment is subject to contract terms, limitations, and exclusions.
Identification of codes in the coding section does not guarantee coverage; see member benefit information.

Background and Scope

Speech-language pathology addresses both communication and swallowing disorders across the lifespan. The policy emphasizes the role of early identification and timely specialist referral: children with significant speech or language delays—such as having fewer than 50 words at 24 months or speech that is largely unintelligible—should be evaluated rather than managed with ‘watchful waiting’. Early intervention programs (for children under three) and timely outpatient therapy referrals improve the likelihood of meaningful, measurable progress. Clinicians should document the diagnosis, past history, measurable goals, and planned treatment amount/frequency/duration to support medical necessity.

Key Definitions

Aphasia — definition and typical causes

DefinitionTotal or partial loss of the ability to use or understand language.

Typical causesUsually caused by stroke, brain disease, or injury.

Context/Test noteListed in policy definitions (V. DEFINITIONS).

Apraxia of speech — definition (includes acquired and childhood types)

DefinitionDisorder of the nervous system that affects the ability to sequence and say sounds, syllables, and words (apraxia of speech).

TypesTwo main types: acquired and childhood.

Associated tests

Policy Summary

PayerCapital Bluecross

PolicySpeech Therapy (Outpatient)

Policy CodePolicy MP 8.002

Change TypeNo material changes

Effective DateDec 1, 2025

Next Review DateJul 31, 2025

Key ActionVerify product-specific prior authorization requirements and document medical necessity, including goals, orders, and prior therapy summaries.

SourceLink

On This Page

Denial Risk

Investigational Services — Potential Noncoverage

Services listed in this policy as investigational are not supported by sufficient evidence and may be denied. Examples include neuromuscular electrical stimulation (e.g., VitalStim®) for dysphagia and central auditory processing disorder (CAPD) testing or treatment.

Neuromuscular electrical stimulation therapy for dysphagia (VitalStim®) — investigational.
Central auditory processing disorder (CAPD) testing/treatment — investigational.
Behavioral/ADHD-related speech services without a covered concurrent diagnosis — investigational.

Denial Risk

Denial Triggers — Noncovered Diagnoses

The following diagnoses are considered not medically necessary for speech therapy and may trigger claim denial when billed as the primary reason for services: F63.89, F90.0, F90.1, F90.2, F90.8. Ensure documentation supports a covered diagnosis when these codes are present.

Not medically necessary ICD-10-CM codes: F63.89, F90.0, F90.1, F90.2, F90.8

Documentation Required

Documentation Requirements — What to Include

Documentation must demonstrate medical necessity and include the patient’s significant past history, diagnoses requiring speech therapy, attending physician name and related orders, contraindications, patient understanding of diagnosis and goals, and a written plan of care with therapy goals (short- and long-term), measurable objectives, and expected timeframe for achievement.

Required documentation elements: history; diagnosis; attending physician and orders; contraindications; patient awareness; therapy goals (short- and long-term) with measurable objectives and expected timeframe; specific treatment type including amount, frequency, and duration; summary of prior therapy and results when appropriate.

Documentation Required

Documentation and Eligibility

Ensure services billed align with the member's specific benefit program and eligibility. Medical policies guide coverage determinations but do not guarantee payment. Contact Provider Services or Member Services for benefit verification if needed.

Verify member eligibility and benefit limitations on the date of service.
Medical policy determinations must be considered alongside plan contract terms and exclusions.

Note

Early Referral Recommended for Children with Significant Delays

Early referral to speech-language pathology and audiology evaluation is recommended for children with significant delays. Immediate referral should be considered for children with fewer than 50 words at 24 months, absence of word combinations, regression of milestones, or speech that remains incomprehensible after two years of age.

Watchful waiting is not recommended for late talkers (vocabulary <50 words at 24 months).
Refer promptly for expressive or receptive language concerns after age two, milestone regression, or persistent unintelligible speech.

Oral Motor Examination; Melody of Speech Assessment; Articulation Evaluation.

Auditory processing disorder (APD/CAPD) — definition and processing difficulties

DefinitionAlso known as auditory perceptual problem, central auditory dysfunction, or central auditory processing disorder (CAPD); a condition in which a person does not process speech/language correctly.

Processing difficultiesMay have difficulty localizing sounds, identifying the source of a sound, or distinguishing one sound from another.

Alternate namesAuditory perceptual problem; central auditory dysfunction; CAPD.

Maintenance program — definition for therapy that preserves function

DefinitionA therapy program consisting of activities that preserve the patient's present level of function and prevent regression of that function.

When it beginsMaintenance begins when therapeutic goals of a treatment plan have been achieved or when no further progress is apparent or expected.

PurposeTo preserve current function rather than produce further measurable improvement.

MAINTENANCE PROGRAM (duplicate entry) — therapy to preserve current function and prevent regression

DefinitionTherapy to preserve the patient's present level of function and prevent regression of that function.

Initiation criteriaBegins when therapeutic goals have been achieved or when no further progress is expected.

Coverage notePolicy states maintenance therapy services are considered not covered except as mandated by Pennsylvania Act 62 of 2008 for Autism Spectrum Disorders.

GRAMMATIC DELAY — definition

DefinitionDelay in use of pronouns, plural-singular forms, syntax, semantics, and related grammatical structures.

Clinical featuresMarked by slowed or atypical development of grammatical morphemes and sentence structure for age.

ContextListed under policy definitions (GRAMMATIC DELAY).

PHONOLOGICAL DISORDERS — definition and examples of error patterns

DefinitionDisorders characterized by predictable, rule-based error patterns affecting more than one sound.

Examples of error patternsFronting, stopping, and final consonant deletion.

Distinguishing featureFocus on phonological (systematic) patterns rather than isolated articulation errors.

PSYCHOSOCIAL SPEECH DELAY — definition and cause

DefinitionSpeech delay resulting from psychosocial deprivation — absence of appropriate physical or social stimuli necessary for emotional, social, and intellectual development.

CauseLack of appropriate stimuli in the physical or social environment required for normal developmental progress.

ImplicationConsideration of environmental and social factors is important in assessment and intervention planning.

RECEPTIVE LANGUAGE DISORDER OR DELAY — definition and referenced tests

DefinitionDifficulty understanding words, sentences, or age-appropriate extended discourse.

Referenced testsClinical Evaluation of Language Fundamentals-3 (CELF-3) receptive subtests; Preschool Language Scale-4 (PLS-4); Testing of Language Development Primary; Receptive One-Word Vocabulary Test for 1–6-year-olds.

Clinical significanceImpaired receptive language affects comprehension and may impact overall communication and learning.