CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Speech-language therapy services — Coverage Criteria

Defines coverage, limitations, coding, and authorization requirements for speech-language therapy services for Neighborhood Health Plan of Rhode Island members across Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySpeech-language therapy services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2020

Next Review DateN/A

Key ActionVerify member eligibility and authorization requirements prior to providing speech-language therapy services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24Medicaid limit per rolling year

NoMedicaid prior auth

YesCommercial/INTEGRITY prior auth

11Listed codes

Coverage Criteria for Speech-Language Therapy

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Medical Necessity and Referral: Services are recommended by a medical provider to address a specific condition, deficit, or dysfunction and must be medically necessary.

Neighborhood may use NCD/LCD, InterQual, EOHHS recommendations, and Clinical Medical Policies (CMPs) to determine medical necessity; providers must verify eligibility, coverage, and authorization prior to rendering services.

Treatment Characteristics: Treatment modalities must be evidence-based, available within the Neighborhood network, and the treatment goals must systematically address a specific diagnosis, deficit, or dysfunction with a reasonable expectation of measurable improvement within a reasonable and predictable timeframe.

Children up to age 3 with developmental delays should be referred to Early Intervention for evaluation and treatment prior to requesting Neighborhood services.

Therapy that is no longer producing measurable benefit is not covered. Specifically, services for conditions where therapeutic goals have been achieved or no progress is apparent or expected should not be billed as rehabilitative speech therapy.

Group therapy is explicitly excluded: services delivered in group settings are not generally covered under this policy.

Services that are considered non-skilled or maintenance—those that can be carried out by the child, family, or caregivers or that only preserve current function—are excluded. Maintenance programs (drills, techniques, exercises that preserve the child's present level of function) and non-skilled services that do not require a qualified provider are not covered.

Swallowing and feeding therapy for behavioral food aversions or selectivity is not covered unless the problem is related to an underlying medical condition or there is documented weight loss or risk of failure to thrive.

The policy lists multiple categories of services that are considered non-skilled, maintenance, duplicative, or otherwise not medically necessary and therefore excluded from coverage.

Examples include: interventions that do not require the skills of a qualified provider or that can be performed by caregivers (non-skilled services); programs designed only to preserve current function (maintenance programs); and services that duplicate other Medicaid-funded services.

Also excluded are services provided for convenience, vocational rehabilitation or job-placement testing, rehabilitative services intended solely to restore function for a specific occupation, and isolated oral sensorimotor or myofunctional therapy when the member does not have a diagnosed neuromuscular disease.

Conditions appropriate for behavioral management rather than medical/rehabilitative therapy should be referred to behavioral services and are not covered here. The policy also excludes services associated with Altered Auditory Feedback (AAF) devices, including the devices themselves.

Billing Codes and Coding Guidance

Covered CPT/HCPCS Codes (listed)mixedCovered

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	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, face-to-face with the patient; each additional 30 minutes.
92610	Evaluation of oral and pharyngeal swallowing function.

1–10 of 11

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Covered CPT/HCPCS Codes (listed) - neutralmixed

No codes listed

Provider Requirements, Prior Authorization, and Denial Risks

Prior Authorization

Prior Authorization Requirements

Medicaid members: Speech therapy is covered without prior authorization but is limited to 24 sessions per rolling year. Commercial and INTEGRITY members: Prior authorization is required before services are rendered. Verify member plan type and authorization requirements prior to scheduling or providing services.

Medicaid: 24 sessions per rolling year, no prior authorization required
Commercial & INTEGRITY: Prior authorization required
Providers must verify member eligibility, coverage, and authorization criteria before rendering services

Documentation Required

Required Documentation and Verification

Providers should ensure orders, treatment plans, and progress notes clearly document the medical necessity and expected measurable improvement. Reference applicable NCD/LCD, InterQual or other accepted criteria, EOHHS recommendations, or Neighborhood Clinical Medical Policies when supporting medical necessity determinations.

Document diagnosis, specific deficits addressed, treatment goals, frequency/duration, and expected timeframe for measurable improvement
Reference applicable NCD/LCD, InterQual or equivalent accepted criteria, EOHHS recommendations, or Neighborhood Clinical Medical Policies
Verify and retain prior authorization documentation when required

Denial Risk

Common Denial Triggers / Exclusions

Do not submit claims for services that meet exclusion or denial criteria. Providers should monitor progress and discontinue rehabilitation when goals are met or no further progress is expected.

Therapy where treatment goals have been achieved or no progress is apparent/expected
Group therapy sessions
Non‑skilled services that do not require a qualified provider
Maintenance programs intended only to preserve current function
Swallowing/feeding therapy for food aversions/selectivity without underlying medical condition or failure to thrive
Isolated oral sensorimotor/myofunctional therapy for tongue thrust or deviant swallow without neuromuscular disease
Vocational rehabilitation, job placement, or occupation‑specific restorative services
Services provided solely for convenience or duplicative of other Medicaid‑funded services
Services and devices associated with Altered Auditory Feedback (AAF)

Note

Provider Notice: Action Required

Action required: confirm payer-specific rules, obtain and retain prior authorizations when applicable, and include clear documentation of medical necessity tied to accepted criteria. Contact Provider Services for questions related to this policy.

Verify eligibility and coverage prior to service
Follow plan-specific Prior Authorization Reference page and Clinical Medical Policies
Provider Services: 1-800-963-1001

Background and Purpose

Speech-language therapy supports the development and rehabilitation of human communication and addresses impairments in speech, language, cognitive-linguistic skills, feeding, and swallowing that arise from illness, injury, congenital, or neurodevelopmental conditions.

Rehabilitative speech services are intended to treat a specific diagnosed condition or deficit and must be recommended by a medical provider with a reasonable expectation of measurable improvement in a predictable time frame. For young children under age 3 with developmental delays, referral to Early Intervention is recommended prior to requesting Neighborhood services.

Definitions

inv-12: Speech-language therapy services — definition and scope

DefinitionSpeech-language therapy services assist with the 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 for speech, language, cognitive-linguistic, feeding, and swallowing disorders when related to a documented medical condition

Medical necessity requirementServices must be medically necessary and recommended by a medical provider to address a specific condition, deficit, or dysfunction

Population noteApplies to members with impairments related to illness, injury, congenital or neurodevelopmental conditions

Treatment intentRehabilitative services must aim for measurable improvement within a reasonable and predictable timeframe