CurrentKaiser PermanentePolicy N/A

Outpatient Speech/Language Therapy Services Coverage Criteria

Clinical review criteria governing medical necessity and coverage of outpatient speech, language, voice, auditory/aural rehabilitation, and swallowing/feeding therapy services for Kaiser Foundation Health Plan of Washington members.

Policy Summary

PayerKaiser Permanente

PolicyOutpatient Speech/Language Therapy Services Coverage Criteria

Policy CodePolicy N/A

Change TypeAdoption of criteria (material)

Effective DateSep 3, 2024

Next Review DateNov 5, 2024

Key ActionSubmit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity for covered services.

SourceLink

POLICY UPDATE CHANGES

MPC approved adoption of criteria for Speech/Language Therapy Services for non-Medicare members and requires 60-day notice with an effective date.

92507,92508,92609,92630,92633Key covered CPT/HCPCS codes listed

6Initial visits allowed without prior auth (WA law)

Electrical stimulationExperimental/unproven for swallowing/feeding

Multiple exclusionsNot medically necessary examples

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Speech/Language Therapy

Speech/language therapy (CPT 92507, 92508, 92609) is medically necessary when ALL of the following are met:

Initial Speech/Language Therapy: The therapy plan includes quantifiable, attainable short- and long-term treatment goals against which progress will be documented; an evaluation completed within the last 12 months by a certified speech-language pathologist that includes age-appropriate standardized tests or measures that quantify the extent of language/speech impairment, performance deviation, or pragmatic skill deficits; the treatment being recommended has the support of a treating licensed healthcare provider (e.g., referral, prescription); the therapy is individualized and meaningful improvement is expected; and the therapy being ordered requires either one-to-one intervention or group setting with supervision by a speech-language pathologist.

Continuation of Speech/Language Therapy: There is documented quantifiable improvement toward established short- and long-term treatment goals; generalization and carryover of targeted skills into the natural environment is occurring; functional progress is being made; goals of therapy are not yet met; and the individual is actively participating in treatment sessions.

Voice Therapy

Voice therapy is medically necessary when ALL of the following are met for significant voice disorders or after vocal cord surgery:

Initial Voice Therapy: The therapy being ordered requires one-to-one intervention and supervision by a speech-language pathologist; the treatment being recommended has the support of a licensed healthcare provider (e.g., referral, prescription); the therapy plan includes quantifiable, attainable short- and long-term treatment goals against which progress will be documented; and the therapy is individualized and meaningful improvement is expected.

Applies to significant voice disorders associated with anatomic laryngeal abnormality, neurologic condition, injury (e.g., vocal nodules or polyps, vocal cord paresis or paralysis, paradoxical vocal cord motion), or provided after vocal cord surgery.

Continuation of Voice Therapy: Generalization and carryover of targeted skills into the natural environment is occurring; functional progress is being made; goals of therapy are not yet met; and the individual is actively participating in treatment sessions.

Auditory/Aural Rehabilitation

Auditory/aural rehabilitation (CPT 92630, 92633) is medically necessary when ALL of the following are met:

Auditory Rehabilitation Criteria: The treatment being recommended has the support of a treating licensed healthcare provider (e.g., referral, prescription); an evaluation has been completed by a certified speech-language pathologist or licensed audiologist that includes standardized speech and/or hearing tests; the therapy being ordered requires one-to-one intervention and supervision by a speech-language pathologist or audiologist; the therapy plan includes quantifiable, attainable short- and long-term treatment goals against which progress will be documented; and the therapy is individualized and meaningful improvement is expected.

Includes treatment following cochlear or auditory brainstem implantation or for hearing impairment due to trauma, tumor, or disease.

Swallowing/Feeding Therapy

Swallowing/feeding therapy is medically necessary when ALL of the following are met:

Swallowing/Feeding Therapy Criteria: Medical necessity is demonstrated by results of testing with a videofluorographic swallowing study (VFSS) or other appropriate testing in combination with an evaluation by a certified speech-language pathologist; the swallowing or feeding disorder is the result of an underlying medical condition; the therapy plan includes quantifiable, attainable short- and long-term treatment goals against which progress will be documented; and the treatment includes a transition from one-to-one supervision to an individual- or caregiver-provided maintenance level on discharge.

The policy lists several services that are not medically necessary or not covered. Developmental speech or language delays that are ≤ one standard deviation (SD) or less below the mean on receptive, expressive, pragmatic, or total language composite scores are not medically necessary. Computer-based learning programs for speech or voice training are not covered unless used specifically for an approved speech-generating device. Services that duplicate therapy already authorized through another discipline (for example, occupational therapy or audiologic services), school-based speech programs, and vocational rehabilitation or job-focused programs are not covered. Maintenance programs consisting of routine, repetitive drills or exercises that do not require SLP skills and can be reinforced by the patient or caregiver are not medically necessary, as are maintenance or preventive treatments intended only to maintain current status or prevent recurrence. Long-term rehabilitative services when significant therapeutic improvement is not expected (therapeutic plateau), therapy to improve general physical condition, swallowing/feeding therapy for food aversions, auditory/aural rehabilitation for presbycusis, and voice therapy without an anatomic laryngeal or vocal cord abnormality are also excluded.

Electrical stimulation for swallowing/feeding disorders is considered experimental, investigational, or unproven and may be denied. Additionally, Washington state law limits utilization management for an initial evaluation and up to six treatment visits in a new episode of care; verify authorization requirements by plan when submitting requests.

Certain procedure or HCPCS codes are considered part of usual evaluation and management and are listed as not medically necessary for separate reimbursement. Examples include S9445 and S9446 (patient education, not otherwise classified; nonphysician provider, group per session).

The policy clarifies that routine patient education and other services that are integral to evaluation/management or duplicated in another authorized therapy are not covered separately. When submitting requests for covered services, include required documentation to demonstrate medical necessity rather than relying on these codes for separate coverage.

Codes and Coverage Status

Considered Medically Necessary when criteria metCPTCovered

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual.
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals.
92521	Evaluation of speech fluency (eg, stuttering, cluttering).
92522	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria).
92523	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language).
92524
92526
92609	Therapeutic services for the use of speech-generating device, including programming and modification.
92610	Evaluation of oral and pharyngeal swallowing function.
92626	Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status.

1–10 of 13

1/2

Considered Not Medically Necessary (part of the usual evaluation and management)HCPCSNot Covered

S9445
S9446	Patient education not otherwise classified, nonphysician provider, group per session

Experimental / UnprovenCPT|HCPCSExperimental

97014	Application of a modality to one or more areas; electrical stimulation (unattended).
97032	Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes.
G0283	Electrical stimulation (unattended) to one or more areas for indications other than wound care as part of a therapy plan of care.

Developmental speech/language delay threshold (≤1 SD = not medically necessary)

ThresholdDevelopmental speech or language delay of one standard deviation (≤ 1 SD) or less below the mean on receptive, expressive, pragmatic, or total language composite scores is considered not medically necessary.

Applies toReceptive, expressive, pragmatic, and total language composite score domains.

Coverage implicationServices for delays at or within 1 SD below the mean are classified as not medically necessary and may be denied or not reimbursed.

Related exclusionsThis threshold is listed alongside other not medically necessary items such as school speech programs, maintenance programs, and duplicative services.

Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Requirements — Washington law

Washington state law (RCW 48.43.016) limits utilization management for a new episode of care: do not require authorization, prior review, or utilization management for an initial evaluation and up to six treatment visits with a contracting provider. For all other services or visits beyond this limit, verify and obtain prior authorization as required by the member's specific Kaiser Permanente plan.

Initial evaluation + up to 6 treatment visits in a new episode of care — no prior authorization required per Washington law
For visits beyond the first 6 or for non-contracting providers — prior authorization may be required; use Pre-authorization Code Check to confirm plan-specific rules

Documentation Required

Required Documentation

Submit documentation sufficient to support medical necessity at the time of request. Include clinical evidence of functional impairment, prior conservative treatments, and progress where applicable.

Include the last 6 months of clinical notes from the requesting provider and/or relevant specialists
Clearly document diagnosis, objective findings, baseline functional status, goals of therapy, treatment plan (frequency, duration), and response to prior treatments
If requesting continued/long-term therapy, provide documentation demonstrating improvement or ongoing medically necessary need (not maintenance alone)

Denial Risk

Denial Triggers / Not Medically Necessary Items

Services that are maintenance, duplicative, educational, or experimental are at high risk of denial. Electrical stimulation for swallowing/feeding disorders is considered experimental/unproven and may be denied. Avoid billing for non-covered educational services or maintenance programs.

Electrical stimulation for swallowing/feeding disorders (e.g., CPT 97014, 97032, G0283) — considered experimental/unproven and subject to denial
Speech services that are primarily educational (reading, writing, spelling) without a documented spoken language disorder — not covered
Maintenance programs or routine/repetitive drills that do not require the skills of a speech-language pathologist — not medically necessary

OpenPayer

Outpatient Speech/Language Therapy Services Coverage Criteria

Medical Necessity — Speech, Language, Voice, Auditory, and Swallowing Therapies

Codes and Coverage Status

Authorization, Documentation, and Billing Guidance

Policy Background

Key Definitions