CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Rehabilitative Speech‑Language Therapy Coverage Criteria

This policy governs coverage, prerequisites, documentation, coding, and exclusions for rehabilitative speech-language therapy services for Neighborhood Health Plan of Rhode Island members across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRehabilitative Speech‑Language Therapy Coverage Criteria

Policy CodePolicy N/A

Change TypeRemoved historical 24-visit benefit limit

Effective DateOct 1, 2020

Next Review DateN/A

Key ActionVerify authorization rules on the plan-specific prior authorization reference page when additional sessions beyond historical limits are needed.

SourceLink

POLICY UPDATE CHANGES

Removed benefit limit of 24 visits for Medicaid and Commercial lines of business effective 04/01/21.

24previously covered without authorization per calendar year (removed)

Children < 3Early Intervention referral recommended

92507-92610,S9152CPT/HCPCS codes listed in policy

Medicaid, INTEGRITY, CommercialLines of business in scope

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Rehabilitative Speech Services

Covered when ALL of the following are met

Medical necessity: Service is medically necessary and recommended by a medical provider to address a specific condition, deficit, or dysfunction related to illness, injury, congenital or neurodevelopmental condition.

Neighborhood may use LCD, NCD, Interqual, EOHHS recommendations, and Clinical Medical Policies to determine medical necessity.

Evidence-based treatment: Treatment modalities are expected to be evidence-based and available within the Neighborhood network.

Treatment must systematically address the diagnosis, deficit, or dysfunction and aim for measurable improvement within a reasonable and predictable period of time.

Early intervention referral: Children up to age 3 with developmental and related conditions should be referred to Early Intervention for evaluation and treatment.

Provider should request services from Neighborhood as appropriate.

Services are not covered when therapy goals have been achieved and no further progress is expected, or when the planned treatment no longer demonstrates measurable benefit. This includes programs that are primarily maintenance in nature—drills, techniques, or exercises intended only to preserve the member’s current level of function and prevent regression. Also excluded are interventions that do not require the skills of a qualified provider (non‑skilled services) or procedures that can be effectively performed by the child, family, or caregivers without clinical oversight.

Additional exclusions include therapy delivered in group settings when such delivery is not appropriate for the member’s needs, and services that duplicate or substantially overlap other Medicaid‑funded programs. Services provided solely for the convenience of the member or provider, vocational rehabilitation or job‑placement screening, and rehabilitative services intended solely to restore function for a specific occupation are not covered. Isolated oral sensorimotor or myofunctional therapy for tongue thrust, deviant or reverse swallow without a diagnosed neuromuscular disease, and interventions associated with Altered Auditory Feedback (AAF) devices (including the devices themselves) are excluded. Feeding/swallowing therapy directed only at food aversions or selectivity that are not the result of an underlying medical or neurodevelopmental condition is not covered unless there is documented weight loss or risk of failure to thrive. Conditions more appropriately managed by behavioral interventions will be referred accordingly.

Coding and Benefit Limits

Listed CPT/HCPCS Codesmixed

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 (stuttering; cluttering).
92522	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria).
92523	Evaluation of speech sound production with evaluation of language comprehension and expression (receptive and expressive language).
92524	Behavioral and qualitative analysis of voice and resonance.
92526	Treatment of swallowing dysfunction and/or oral function for feeding.
92607	Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour.
92608	Evaluation for prescription for speech-generating augmentative and alternative communication device; each additional 30 minutes.
92610	Evaluation of oral and pharyngeal swallowing function.

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Prior-authorized sessions without prior auth (historical)

Historical benefit limit24 sessions per calendar year previously covered without prior authorization for Speech Therapy (additional sessions required authorization)

Effective changeBenefit limit of 24 visits removed for Medicaid and Commercial lines of business effective 04/01/21

Applies toReferenced in INTEGRITY and Commercial plan communications (verify current plan-specific prior authorization rules)

Action for providersFor services beyond historical 24-session guidance, verify current prior authorization requirements on the plan-specific prior authorization reference page

Provider Requirements, Authorization, and Denial Triggers

Prior Authorization

Prior Authorization Required

Speech therapy is covered without prior authorization for up to 24 sessions per calendar year. Additional sessions beyond 24 in a calendar year require prior authorization from Neighborhood Health Plan of Rhode Island.

Applies to rehabilitative speech services for applicable lines of business.
Prior authorization must document medical necessity and expected measurable improvement.

Documentation Required

Required Documentation

The medical record must support the services billed and substantiate medical necessity per CMS and national claims standards. Providers must maintain documentation that justifies the diagnosis, treatment plan, progress toward goals, and rationale for continuing therapy.

Follow CMS documentation standards and National Claims Standards.
Include diagnosis (ICD-10-CM), relevant assessment findings, treatment goals, and progress notes.
Retain records to support billing and any requested prior authorization.

Denial Risk

Triggers for Denial

Services may be denied or payment may be adjusted when medical necessity is not met, required documentation is missing or insufficient, or when prior authorization (when required) was not obtained. Providers are responsible for verifying member eligibility and authorization requirements before rendering services.

Not medically necessary: diagnosis/treatment does not meet policy or accepted criteria (LCD, NCD, InterQual, CMP).
Insufficient documentation: records do not support billed services, lack progress notes, or lack clear treatment goals.
No authorization: additional sessions beyond the 24-session calendar year limit without approved prior authorization.
Claims submitted outside timely filing or not following coding/claim standards may be denied.

Background

Speech‑language therapy services address impairments in communication, cognition, feeding, and swallowing related to illness, injury, congenital, or neurodevelopmental conditions. The aim of rehabilitative speech services is to evaluate and treat specific deficits with evidence‑based, targeted interventions that produce measurable improvement in a reasonable and predictable timeframe. For young children with developmental concerns, providers should refer children under age three to Early Intervention for evaluation and treatment as appropriate.

Definitions

Speech-language therapy — definition of services

DefinitionServices that assist with development of human communication and evaluate and/or treat speech, language, cognitive-linguistic, feeding, or swallowing impairments related to a specific illness, injury, or congenital or neurodevelopmental condition

Scope of servicesIncludes evaluation and treatment of speech, language, voice, communication, auditory processing, cognitive-linguistic skills, feeding and swallowing

Evidence-based requirementTreatment modalities are expected to be evidence-based and available within the Neighborhood network

Early Intervention referralChildren up to age 3 with developmental and related conditions should be referred to Early Intervention for evaluation and treatment

Revision History

2021-04-01policy_updateLatest

Removed the benefit limit of 24 speech therapy visits per calendar year for Medicaid and Commercial lines of business.

2021-01-01policy_update

Updated benefit limit and authorization requirements for Commercial and INTEGRITY; Medicaid limit changed to calendar year instead of rolling year.

2020-10-01policy_effective

Policy effective date established.

2020-11-05policy_review

Policy reviewed and approved for changes (entry dated 11/05/20).

2020-09-14policy_review

Policy reviewed and approved (entry dated 09/14/20).