CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Speech and Language Therapy

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This policy explains the clinical information MassHealth uses to determine medical necessity for speech-language therapy delivered in outpatient and home settings, including coverage criteria, noncoverage circumstances, prior authorization, and required documentation.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Speech and Language Therapy

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJul 1, 2005

Next Review DateN/A

Key ActionObtain prior authorization for speech-language therapy after the 35th visit within a 12-month period and submit the request through POSC or the PA-1 form with supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

After visit 35Prior authorization threshold within a 12-month period

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CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Speech and Language Therapy

Customize your policy alerts

Sign up for all Massachusetts Executive Office of Health and Human Services policy alerts

Know when Massachusetts Executive Office of Health and Human Services releases new policies or updates existing guidance.

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Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Speech and Language Therapy

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJul 1, 2005

Next Review DateN/A

Key ActionObtain prior authorization for speech-language therapy after the 35th visit within a 12-month period and submit the request through POSC or the PA-1 form with supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

After visit 35Prior authorization threshold within a 12-month period

Communication, cognition, feeding, and swallowing impairment areas identified for potential coverage

2Covered service types

9Examples of noncoverage circumstances listed

All requiredMedical necessity documentation requirements

Medical Necessity and Noncoverage Criteria

Clinical coverage criteria

Covered when all major criteria are met and documentation demonstrates potential for measurable, objective progress or prevention of worsening function.

Clinical coverage

Qualifying communication or swallowing disorder
- Speech sound production: Articulation, apraxia, dysarthria, or another speech sound production impairment.
- Resonance: Hypernasality, hyponasality, or another resonance impairment.
- Voice: Phonation quality, pitch, respiration, or another voice impairment.
- Fluency: Stuttering, cluttering, or another fluency impairment.
- Language: Comprehension, expression, pragmatics, or another language impairment.
- Cognition affecting communication: Attention, memory, problem solving, executive functioning, or another cognitive impairment affecting communication.
- Feeding and swallowing: Oral, pharyngeal, esophageal, or another feeding or swallowing impairment.
Referral: The member is referred in writing to a licensed-certified speech-language pathologist for evaluation and treatment as prescribed by a licensed physician or licensed nurse practitioner based on a medical history and physical examination.
Comprehensive evaluation: A comprehensive evaluation by a licensed, certified speech-language pathologist establishes a communication or swallowing disorder requiring speech-language therapy.
Requested service type
- Diagnostic and evaluation services: Services determine the cause, type, and severity of the communication or swallowing disorder and the need for therapy.
- Therapeutic services: Services are intended to improve the communication or swallowing disorder.
Medical necessity treatment standards: The treatment requires the skill of a licensed, certified speech-language pathologist; is expected to significantly improve the condition within a reasonable and predictable period or prevent worsening; uses an appropriate amount, frequency, and duration under recognized standards; and is provided by a licensed, certified speech-language pathologist to a member under the care of a licensed physician or nurse practitioner with a written treatment plan developed in consultation with a licensed speech-language pathologist.

Non-diagnostic, non-therapeutic, routine, or repetitive services that maintain general welfare are not medically necessary when they do not require the skills of a licensed, certified speech-language pathologist.

Speech-language therapy is not medically necessary for a communication or swallowing disorder that is not associated with an acute or chronic medical condition, neurological disorder, injury, congenital anomaly, or disability.

Therapy is not medically necessary when it replicates concurrent services, including speech-language therapy provided in another setting, occupational therapy with similar treatment goals, plans, and therapeutic modalities, or another therapy with similar goals.

Services are not medically necessary when they are primarily educational, emotional, or psychological in nature and are provided in a school or behavioral health setting, including services for psychosocial speech delay, behavioral problems, or attention disorders.

Treatment for a self-correcting dysfunction is not medically necessary, including treatment for natural dysfluency or developmental articulation errors.

Treatment directed to dialect or accent reduction or to developing skills in a nondominant language is not medically necessary.

Treatment that is primarily vocationally or recreationally based is not medically necessary.

Treatment for developmental stuttering or stammering, or for stuttering or stammering not caused by a neurological condition or brain injury, is not medically necessary.

Speech-language therapy is not medically necessary when the service does not require the skills of a licensed, certified speech-language pathologist, when the condition lacks a qualifying medical etiology, or when the requested care is routine, repetitive, or duplicative of concurrent therapy.

Initial or continuing speech-language therapy is not medically necessary when clinical documentation or a written treatment plan does not support the need for care. Documentation must support the diagnosis, severity, evaluation findings, prognosis, rehabilitation potential, measurable goals, treatment approach, and measurable progress where applicable.

Authorization Threshold

Speech-language therapy visit threshold

Authorization triggerPrior authorization is required after the 35th visit within a 12-month period.

Applies toAll members receiving speech-language therapy services.

Extended-request submissionRequests beyond the 35th visit must be submitted by a speech-language pathologist and accompanied by clinical documentation from a licensed physician or licensed nurse practitioner supporting the requested services.

Authorization and Documentation Requirements

Prior Authorization

Prior Authorization After Visit 35

Prior authorization is required for all members after the 35th speech-language therapy visit within a 12-month period. Requests beyond visit 35 must be submitted by a speech-language pathologist and supported by clinical documentation from a licensed physician or licensed nurse practitioner.

Applies to services beyond the 35th visit in any 12-month period.
The request must include documentation supporting the medical necessity of the requested services.

Prior Authorization

Submit PA Through POSC or PA-1

The licensed, certified speech-language pathologist requesting prior authorization must submit all information pertinent to the diagnosis and clinical need. Providers are strongly encouraged to submit requests electronically.

Submit through the Provider Online Service Center (POSC), or use the MassHealth Prior Authorization Request (PA-1) paper form.
Attach pertinent clinical documentation; if mailing the PA-1, use the address on the back of the form.

Speech-Language Therapy Overview

Speech-language therapy addresses the diagnosis, evaluation, and treatment of communication and swallowing disorders, including dysphagia, speech-language disorders, and cognitive-communication disorders. Impairments may involve speech sound production, resonance, voice, fluency, language, cognition affecting communication, feeding, or swallowing. Services may improve, develop, correct, or rehabilitate affected skills, or prevent worsening related to acute or chronic medical conditions, congenital anomalies, developmental conditions, or injuries.

Covered Service and Condition Definitions

Speech-language therapy services

PurposeServices necessary for the diagnosis or evaluation and treatment of communication disorders.

Swallowing disordersIncludes disorders resulting from swallowing, including dysphagia.

Communication conditionsIncludes speech-language and cognitive-communication disorders.

Communication disorders

Speech sound productionDisorders affecting speech sound production.

Resonance and voiceDisorders affecting resonance or voice.

Fluency

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Speech and Language Therapy

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJul 1, 2005

Next Review DateN/A

Key ActionObtain prior authorization for speech-language therapy after the 35th visit within a 12-month period and submit the request through POSC or the PA-1 form with supporting documentation.

SourceLink

On This Page

POSC access questions: MassHealth Customer Service Center, 1-800-841-2900.

Documentation Required

Document Diagnoses and Symptom Severity

Document the primary diagnosis and ICD-CM code for which treatment is requested, the secondary diagnosis and ICD-CM code specific to the medical condition, and the severity of signs and symptoms pertinent to the communication or swallowing disorder.

Include the primary diagnosis name and ICD-CM code.
Include the secondary diagnosis name and ICD-CM code specific to the medical condition.
Describe the severity of pertinent signs and symptoms.

Documentation Required

Provide a Comprehensive Speech-Language Evaluation

Provide a written comprehensive evaluation prepared by a licensed, certified speech-language pathologist. The evaluation must describe the member's background, underlying medical diagnosis and condition, medical status, disability, prior functional level when relevant, psychosocial status, treatment history, and documented progress.

Include comprehensive speech- and language-evaluation findings, the communication or swallowing diagnosis, underlying etiology, and date of onset or exacerbation.
Include standardized assessment results and subjective descriptions of current communicative or swallowing functioning.
Interpret the results, including need for intervention or referral, prognosis, expected change with and without intervention, rehabilitation potential, risk factors, and relevant comorbid conditions.

Documentation Required

Submit a Written Treatment Plan

Submit a written treatment plan that supports the requested therapy and defines how treatment will improve function. The plan must include measurable goals, planned interventions, and the amount and schedule of care.

Specify short- and long-term measurable functional treatment goals.
Identify treatment types, techniques, and interventions.
State the amount, frequency, and duration of treatment and the estimated time to reach goals.
Include member and primary-caregiver education, plus a summary of prior treatment, response, measurable progress, problems encountered, and goals met.

Documentation Required

Justify Concurrent Therapy

For a member receiving speech-language therapy in another setting, additional services must be substantially different from the therapy already being provided. Justification must establish both the medical basis for the additional services and the distinct goals they address.

Describe how the requested treatment differs substantially from services in the other setting.
Explain the medical necessity and goals for the additional therapy.
Consider concurrent services with similar goals, plans, or modalities, including occupational therapy.

Documentation Required

Support Extended Therapy With Clinical Documentation

Requests for therapy beyond visit 35 require submission by the requesting speech-language pathologist and supporting clinical documentation. Clinical information from a licensed physician or licensed nurse practitioner must accompany the request and support the services being requested.

Submit the clinical documentation with the PA request.
Ensure documentation supports the diagnosis, medical necessity, requested duration, and continuing need for therapy.

Denial Risk

Avoid Routine Services or Unqualified Etiologies

Coverage may be denied when services do not require the skills of a licensed, certified speech-language pathologist or are non-diagnostic, non-therapeutic, routine, repetitive, or intended only to maintain general welfare. Denial risk also applies when the disorder is not associated with a qualifying acute or chronic medical condition, neurological disorder, injury, congenital anomaly, or disability.

Avoid billing routine or duplicative procedures that do not require skilled speech-language pathology.
Document the qualifying medical etiology for the communication or swallowing disorder.

Denial Risk

Watch for Noncovered Treatment Purposes or Conditions

Services may be denied when treatment is primarily educational, emotional, psychological, vocational, or recreational, or is directed to dialect or accent reduction, developing skills in a nondominant language, or a self-correcting condition. Examples include psychosocial speech delay, behavioral problems, attention disorders, natural dysfluency, and developmental articulation errors.

Do not present school-based or behavioral-health educational, emotional, or psychological treatment as medically necessary speech-language therapy.
Treatment for developmental stuttering or stammering is not covered when it is not caused by a neurological condition or brain injury.

Denial Risk

Support Medical Necessity With Complete Documentation

Initial or continuing therapy may be denied when the clinical documentation or written treatment plan does not establish medical necessity. The record must substantiate the diagnosis, severity, evaluation findings, expected benefit, measurable goals, planned interventions, and ongoing progress or need for continued care.

Include all required diagnostic, evaluation, treatment-plan, and progress information.
Document measurable progress toward previously defined goals, changes in condition, problems encountered, and goals met during prior therapy.

Denial Risk

Avoid Duplicative Concurrent Therapy

Concurrent services may be denied when the requested speech-language therapy replicates treatment being delivered in another setting or has similar goals, plans, or therapeutic modalities. Additional therapy must be substantially different and medically justified.

Explain the distinction between the requested therapy and existing speech-language, occupational, or other therapy.
State the medical basis and separate goals for the additional services.

Disorders affecting fluency.

LanguageDisorders affecting language.

CognitionDisorders affecting cognition.