CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Outpatient Speech‑Language Therapy Services — Coverage Criteria

Defines coverage, authorization, coding, and documentation requirements for outpatient speech-language pathology 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

PolicyOutpatient Speech‑Language Therapy Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeAuthorization and coding updates

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from Evolent Health for all speech therapy services per line of business effective dates.

SourceLink

POLICY UPDATE CHANGES

Updated authorization language and dates for INTEGRITY, Medicaid, and Commercial lines to reflect management by Evolent Health and new authorization effective dates.

Added requirement that certain speech therapy CPT codes must be billed with GN modifier; claims without the modifier will deny.

YesAuthorization required

RequiredGN modifier required

<=3 yrsEarly Intervention referral

AuditableDocumentation auditable

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Coverage Criteria for Outpatient Speech-Language Pathology

Covered — Rehabilitative speech services

Covered when ALL of the following are met

Rehabilitative speech services: Recommended by a medical provider to address a specific condition, deficit, or dysfunction

Treatment modalities must be evidence-based and available within the Neighborhood network.

Expectations of improvement: Treatment goals must systematically address a specific diagnosis, deficit, or dysfunction and the patient must have a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time

Early Intervention referral: Children up to age 3 with developmental delays and related conditions have been referred to Early Intervention for evaluation and treatment prior to requesting Neighborhood services

The following services are considered not covered or are exclusions from rehabilitative speech-language services: therapy provided when therapeutic goals have been achieved and no further progress is expected; non-skilled services that do not require the skills of a qualified provider or that can be performed by the child, family, or caregivers; and maintenance programs such as drills, techniques, and exercises intended only to preserve current function and prevent regression.

Also excluded are swallowing/feeding therapy for food aversions or food selectivity when these issues are not the result of an underlying medical or neurodevelopmental condition, unless there is documented weight loss with risk of failure to thrive; isolated oral sensorimotor or myofunctional therapy for tongue thrust, deviant/reverse swallow, or oral myofunctional disorders in members without a diagnosed neuromuscular disease; and services associated with Altered Auditory Feedback (AAF) devices (including the devices themselves).

Additional exclusions include rehabilitative services provided solely for convenience, vocational rehabilitation or job adaptability testing, services to restore function specifically for a member’s occupation, conditions appropriate for behavioral management rather than medical/rehabilitative therapy, and any services that would result in duplicative or substantially identical services already provided by another Medicaid-funded program.

Maintenance and non-skilled services are explicitly limited: programs whose sole purpose is to maintain a current level of function with no reasonable expectation of measurable improvement are not covered. Services that can be effectively carried out by caregivers or do not require a qualified provider fall under the non-skilled exclusion and should not be billed as rehabilitative therapy.

For swallowing and feeding interventions, coverage is limited to cases with an underlying medical or neurodevelopmental condition or where there is clinically significant weight loss or risk of failure to thrive. Swallowing/feeding therapy for behavioral food selectivity or aversions without such medical risk is excluded. Similarly, isolated oral sensorimotor/myofunctional therapy (e.g., treatment solely for tongue thrust or deviant swallow) is not covered unless the member has a diagnosed neuromuscular disease that justifies the intervention.

CPT/Modifier Requirements and Code Lists

Medicare Sometimes/Always Therapy Speech Therapy Evaluation and Treatment CodesCPTCovered

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
92526	Treatment of swallowing dysfunction and/or oral function for feeding
92608	Therapeutic services for the use of speech-generating device (procedure)
92609	Therapeutic services for the use of speech-generating device, including programming and modification
92610	Evaluation of oral and pharyngeal swallowing function
97129	Cognitive therapy: initial 15 minutes (direct one-on-one)
97130	Cognitive therapy: each additional 15 minutes

Speech Therapy Evaluation and Treatment CodesCPTCovered

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 with evaluation of language comprehension and expression
92524	Behavioral and qualitative analysis of voice and resonance
92597	Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech
92607	Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour
S9152	Speech therapy, re-evaluation

GN modifier requirement

RequirementGN modifier is required on the listed Medicare sometimes/always therapy CPT codes; claims for these codes will deny if the GN modifier is not appended.

Affected codes92507, 92508, 92526, 92608, 92609, 92610, 97129, 97130

PurposeDistinguishes the discipline under which the service was delivered per CMS Medicare sometimes/always therapy guidance.

Authorization, Billing, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Authorization is required for all speech therapy services per line of business management by Evolent Health. Effective dates vary by line of business: for Commercial and Medicaid authorization is required as of June 15, 2024; for INTEGRITY authorization is required as of March 31, 2025.

Commercial and Medicaid: Authorization required effective 06/15/2024 (Evolent Health management).
INTEGRITY: Authorization required effective 03/31/2025 (Evolent Health management).

Documentation Required

Recordkeeping and Documentation

Providers must document the ordering/referring provider in the member's medical record and note the referring provider in Box 17 on the claim. Neighborhood reserves the right to request medical records for any service billed; documentation must support the services billed and the medical necessity of those services. Neighborhood follows CMS standards for proper documentation and providers may be subject to audit.

Key Definitions

Rehabilitative speech services — scope

Scope — core definitionSpeech-language therapy services assist with development of 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.

Clinical focusEvaluation and treatment of speech, language, voice, communication, auditory processing, cognitive-linguistic deficits, and swallowing/feeding disorders.

Treatment expectationsServices should be evidence-based, address specific deficits tied to a diagnosis, and have a reasonable expectation of measurable improvement in a predictable time frame.

Pediatric considerationChildren up to age 3 with developmental delays should be referred to Early Intervention prior to requesting Neighborhood services.

Background

Speech-language therapy evaluates and treats impairments in speech, language, cognitive‑linguistic function, feeding, and swallowing that are attributable to illness, injury, congenital conditions, or neurodevelopmental disorders. These rehabilitative services are intended to address specific deficits tied to a diagnosis and should be evidence‑based with a reasonable expectation of measurable improvement within a predictable timeframe.

For young children, services must follow established pathways: children under age three with developmental delays should be referred to Early Intervention prior to requesting Neighborhood services. Rehabilitative speech therapy is provided when recommended by a medical provider and when treatment goals systematically target the identified diagnosis or functional deficit.