ModifiedOklahoma Health Care AuthorityPolicy N/A

Pediatric Speech-Language Evaluation Coverage Criteria

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This guideline governs medical-necessity and prior-authorization requirements for pediatric speech-language pathology evaluations, including evaluations of fluency, speech sound production, language, voice, and resonance. It applies to members ages 0 through 20 at the time of evaluation and establishes eligibility, documentation, evaluation-report, and continuation requirements.

Policy Summary

PayerOklahoma Health Care Authority

PolicyPediatric Speech-Language Evaluation Coverage Criteria

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective DateJun 2, 2025

Last ReviewMay 1, 2025

Next Review DateJun 1, 2028

Key ActionSubmit prior authorization with the required qualified-provider order, clinical support, HCA-61 form, and applicable SC-16 form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Ages 0-20

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ModifiedOklahoma Health Care AuthorityPolicy N/A

Pediatric Speech-Language Evaluation Coverage Criteria

Customize your policy alerts

Sign up for all Oklahoma Health Care Authority policy alerts

Know when Oklahoma Health Care Authority releases new policies or updates existing guidance.

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Policy Summary

PayerOklahoma Health Care Authority

PolicyPediatric Speech-Language Evaluation Coverage Criteria

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective DateJun 2, 2025

Last ReviewMay 1, 2025

Next Review DateJun 1, 2028

Key ActionSubmit prior authorization with the required qualified-provider order, clinical support, HCA-61 form, and applicable SC-16 form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Ages 0-20

4Covered evaluation codes requiring prior authorization

90 daysEvaluation completion deadline

AnnuallyContinued-service evaluation frequency

Medical necessityCoverage prerequisite

Coverage Criteria

General coverage

Covered when all applicable general requirements are met:

General coverage: Medical necessity is demonstrated through adequate medical records in accordance with OAC 317:30-3-1(f).

General coverage: The member is ages 0 through 20 at the time of evaluation.Age 0-20

General coverage: The speech-language pathology evaluation is medically appropriate.

Evaluation eligibility

Eligibility for evaluation is established when any one of the following factors is present:

Evaluation eligibility: Referral because of a suspected speech, language, or communication disorder from the individual, family member, audiologist, physician, teacher, other speech-language pathologist, or interdisciplinary team.

Evaluation eligibility: Failure to pass a screening assessment for communication and/or swallowing function.

Evaluation eligibility: The individual cannot communicate functionally across environments and communication partners.

Evaluation eligibility: Communication abilities are not comparable to those of peers with the same chronological age, gender, ethnicity, or cultural and linguistic background.

Evaluation eligibility: Communication skills negatively affect health, safety, social status, or vocational status.

Evaluation eligibility: The individual, family, or guardian seeks services to achieve or maintain functional communication, including alternative and augmentative communication.

Continuation and reevaluation

Continuation and reevaluation require all of the following:

Continuation evaluation: Evaluation procedures are performed annually because symptoms and impairment level may change and services may no longer be medically necessary.Annually

Linguistic and cultural assessment: The SLP considers linguistic difference versus disorder and selects an assessment instrument that is fair and efficient for the child's cultural and linguistic background.

Translated English-standardized tests may not retain valid psychometric properties.

Reevaluation report: Reevaluation includes the same procedures as the initial evaluation and detailed information regarding progress toward goals from the previous authorization period.

Covered Services and Coding Requirements

Covered CPT CodesCPTCovered

92521	Evaluation of speech fluency (e.g., stuttering, cluttering)
92522	Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria)
92523	Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language)
92524	Behavioral and qualitative analysis of voice and resonance

Pediatric age at evaluation

Covered populationMembers ages 0 through 20 at the time of evaluation

ServiceSpeech-language pathology evaluation

Coverage conditionThe evaluation must be medically appropriate and medical necessity must be demonstrated through adequate medical records

Evaluation completion deadline

Completion deadlineThe evaluation must be completed within 90 days of the date the order was signed or referral was made

Authorization periodPrior authorization may be approved for up to 90 days from the physician's signature on the order or referral

Prior Authorization and Documentation Actions

Prior Authorization

Obtain PA for covered evaluation codes

Prior authorization is required for evaluation of speech fluency, speech sound production, speech sound production with evaluation of language comprehension and expression, and behavioral and qualitative analysis of voice and resonance.

CPT 92521, 92522, 92523, and 92524 require PA.
The PA request must include the required order, clinical support, HCA-61 form, and applicable SC-16 form.

Prior Authorization

Track the 90-day authorization period

Prior authorization for the evaluation may be approved for up to 90 days from the date of the physician's signature on the order or referral for the requested service.

Clinical Background

Speech-language evaluations identify developmental or acquired disorders affecting speech, language, voice, fluency, cognition-linguistic skills, or general communication. Evaluations may be appropriate when there are concerns about age-appropriate, functional communication skills, including conditions such as stuttering and voice disorders; an individual may have more than one communication disorder and may require more than one type of evaluation.

Evaluation findings are used to establish medical necessity, identify functional communication needs, and develop treatment strategies that support communication across home, school, community, social, and vocational environments.

Definitions

Central Auditory Processing Disorder (CAPD)

DefinitionDeficits in the neural processing of auditory information in the central auditory nervous system that are not due to higher-order language or cognition

Coexisting conditionsCAPD may coexist with attention-deficit/hyperactivity disorder, language impairment, or learning disability

ExclusionCAPD is not due to peripheral hearing loss, including conductive or sensorineural hearing loss

Communication disorder

DefinitionAn impairment in the ability to receive, send, process, and comprehend verbal, nonverbal, or graphic symbol systems

Areas affectedA communication disorder may involve hearing, language, speech, or combinations of these

Policy Summary

PayerOklahoma Health Care Authority

PolicyPediatric Speech-Language Evaluation Coverage Criteria

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective DateJun 2, 2025

Last ReviewMay 1, 2025

Next Review DateJun 1, 2028

Key ActionSubmit prior authorization with the required qualified-provider order, clinical support, HCA-61 form, and applicable SC-16 form.

SourceLink

On This Page

Exception handlingRequests outside the guideline are referred for medical director review

Continuation evaluation frequency

FrequencyEvaluation procedures are required annually for continued services

ReasonSymptoms and level of impairment may change over time

Reevaluation contentReevaluation must include the same procedures as the initial evaluation and detailed progress toward goals from the previous authorization period

Current hearing screening for initial evaluation

Initial evaluation requirementHearing screening should be performed within one year of an initial evaluation

Failed screeningA failed hearing screening should result in referral to an audiologist for further evaluation

Repeat testingAnother hearing evaluation is not necessary after a normal screening or prior audiological evaluation unless there is concern, a change in medical status, or another known risk factor

Current ordering-provider clinical documentation

Documentation ageOrdering-provider clinical documentation must be current within one year

ExampleA current well-child visit may support medical necessity

Required supportDocumentation must support medical necessity for the requested ICD-10-CM code; for codes 92521, 92522, and 92524, it must support the specific code requested

Documentation Required

Submit a qualified-provider order

Submit a signed and dated order from a contracted MD, DO, PA, CNP, or APRN. The order must designate speech therapy and include the applicable ICD-10-CM diagnosis and description.

Documentation Required

Document medical necessity from the ordering provider

Submit current clinical documentation from the ordering provider, such as a well-child visit within the past year, supporting medical necessity for the requested ICD-10-CM diagnosis.

For CPT 92521, 92522, and 92524, documentation must support the need for the specific code requested.

Documentation Required

Include required authorization forms

Include a completed HCA-61 Therapy Prior Authorization Request form with the PA submission and, when applicable, submit the Change of Provider Form SC-16.

Documentation Required

Complete all required evaluation-report elements

The evaluation report must include the required history, screening, examination, assessment, interpretation, medical-necessity rationale, prognosis, and plan-of-care elements.

Relevant case history, including birth, development, medical, linguistic, and previous-service history.
Hearing-screening information, oral-mechanism examination, and respiratory, voice, and fluency information.
Standardized and/or professionally acceptable observational assessment, analysis of results, and interpretation of all assessment measures.
A plan of care with functional measurable goals, baseline measures, support levels, parental involvement, home program, cultural sensitivity, and evidence-based practices.

Documentation Required

Support alternative assessment methods

If standardized testing cannot be completed, document a valid rationale and use dynamic, informal, and functional communication assessment. If a standardized articulation assessment cannot be completed, include a detailed SLP narrative addressing speech productions, sound combinations, phonological processes, intelligibility, and comparison with typical development.

Documentation Required

Obtain CCC-SLP cosignature

All documents completed by a Clinical Fellow or SLP-A must be co-signed by a licensed, certified Speech-Language Pathologist (CCC-SLP).

Denial Risk

Prevent documentation-related coverage issues

Requests may not meet coverage requirements when medical necessity is not demonstrated through adequate medical records, when the required contracted qualified-health-professional order is missing, or when required supporting documentation is incomplete.

Demonstrate medical necessity through adequate medical records.
Include the required signed and dated order and supporting clinical documentation.

Denial Risk

Confirm the member's covered age range

The covered pediatric evaluation benefit applies when the member is ages 0 through 20 at the time of evaluation and the service is medically appropriate.

Denial Risk

Meet evaluation timing requirements

The evaluation must be completed within 90 days of the signed order or referral. Requests outside the guideline will be referred for medical director review.

Course and severityIt may range from mild to profound and may be developmental or acquired

Speech-Language Pathologist (SLP)

LicensureA fully licensed speech-language pathologist

EducationHolds a master's degree

CertificationASHA-certified and holds the Certificate of Clinical Competence in Speech-Language Pathology

Licensed Qualified Clinician

Qualified clinicianMay be a fully licensed Speech-Language Pathologist or a speech-language pathology Clinical Fellow

Clinical Fellow pathwayThe Clinical Fellow has completed the necessary educational requirements and work experience for the Certificate, or has completed the academic program and is acquiring supervised work experience

Credential goalThe supervised experience is directed toward qualification for the Certificate of Clinical Competence

Screening

DefinitionA process for identifying young children at risk for communication deficits

PurposeScreening allows evaluation to establish eligibility and supports more in-depth assessment to guide development of an intervention program

DeterminationThe aim is to determine whether a child is likely to show deficits in communication development

Speech-Generating Device (SGD)

Device typeAn augmentative or alternative durable medical device that generates speech

UseIt supplements existing speech or serves as an alternative when speech is absent or nonfunctional

Eligible communication needIt provides an individual with severe speech impairment the ability to meet functional speaking needs

Speech-Language Therapy (Intervention)

DefinitionTreatment of impaired speech or language production, voice production, cognitive-linguistic skills, or general communication abilities

Potential causesImpairment may result from disease, injury, developmental delay, or a surgical procedure

Treatment scopeIntervention may address speech or language, voice, cognitive-linguistic skills, and general communication abilities