Currentselect_healthPolicy CCP.1302

Speech therapy

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Defines medical necessity criteria, limitations, and background for speech therapy services (speech disorders, fluency, voice, swallowing, pediatric feeding disorders, and oral aversion) used by Select Health of South Carolina to make coverage determinations for members.

Policy Summary

Payerselect_health

PolicySpeech therapy

Policy CodePolicy CCP.1302

Change TypeNo material change

Effective DateJun 1, 2025

Last ReviewDec 1, 2025

Next Review DateApr 1, 2027

Key ActionObtain documentation showing objective testing or clinical assessment demonstrating impairment or pediatric feeding disorder plus a defined care plan with measurable goals before requesting coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All of the followingCore coverage requirement

Includes feedingFeeds/swallow covered

Unsupported servicesLimitations listed

When condition changesReevaluation

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Currentselect_healthPolicy CCP.1302

Speech therapy

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Sign up for select_health Policy CCP.1302 alerts

Get alerted when Policy CCP.1302 changes without checking for updates manually.

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Policy Summary

Payerselect_health

PolicySpeech therapy

Policy CodePolicy CCP.1302

Change TypeNo material change

Effective DateJun 1, 2025

Last ReviewDec 1, 2025

Next Review DateApr 1, 2027

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All of the followingCore coverage requirement

Includes feedingFeeds/swallow covered

Unsupported servicesLimitations listed

When condition changesReevaluation

Coverage and Medical Necessity Criteria

Medical necessity criteria

Covered when ALL of the following are met

Core coverage nodes

Either
- Option 1: Objective standardized testing does not demonstrate age-appropriate speech-language communication (e.g., as referenced by Brady, Gubiani, Roulstone, Tosh).
- Option 2: Clinical assessment or objective standardized testing demonstrates a pediatric feeding disorder (impaired oral intake that is not safe or age-appropriate) with associated medical, nutritional, feeding skill, or psychosocial dysfunction (per WHO ICF).

Care plan and goals: 2) Services are administered as part of a care plan with clearly defined type, amount, duration, and frequency of therapy services, and clearly defined therapeutic goals; amount, frequency, and duration must be reasonable under accepted standards of practice.

Provider qualifications: 3) Services are administered by a trained, licensed healthcare professional experienced in the diagnosis and treatment of speech and feeding disorders.

Expected benefit: 4) The member's condition is expected to improve from the services provided.

The policy excludes services provided primarily to achieve academic or educational goals, such as instruction targeting grammar, vocabulary, or reading. It also excludes speech therapy delivered in a language other than the member’s language at home. These exclusions reflect the policy position that therapy must address a clinical communication or feeding/swallowing impairment rather than educational language instruction or services limited by language-of-service mismatch.

Services are considered not medically necessary when there is no evidence of improved outcomes or no defined benefit in state or federal policy. Examples specified in the policy include: therapy for academic goals (e.g., grammar, vocabulary, reading); therapy administered in a language other than the member’s home language; voice therapy for gender reassignment when there is no functional limitation; and speech therapy when the member already can feed or swallow adequately to maintain nutrition, hydration, and pulmonary status or manage oral/pharyngeal saliva accumulation. The policy also requires periodic reevaluation by a trained, licensed clinician when the member’s condition significantly changes or when requested by the Plan to determine ongoing medical necessity.

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

PA trigger — medical necessity documentation required

Prior authorization is typically required when documentation shows either (1) objective standardized testing that does not demonstrate age‑appropriate speech‑language communication, or (2) clinical assessment or objective testing demonstrating a pediatric feeding disorder (impaired oral intake that is not safe or age‑appropriate) with associated medical, nutritional, feeding skill, or psychosocial dysfunction. In addition, the request must show the service is part of a care plan with defined type, amount, duration, frequency, and therapeutic goals; that amount/frequency/duration are reasonable; that a trained, licensed professional experienced in speech/feeding disorders will provide care; and that the member’s condition is expected to improve from the services provided.

Either: objective standardized testing does not demonstrate age‑appropriate speech‑language communication OR testing/clinical assessment demonstrates a pediatric feeding disorder with associated dysfunction.
Care plan with clearly defined type, amount, duration, frequency, and therapeutic goals; amount/frequency/duration reasonable under accepted standards.
Services administered by a trained, licensed healthcare professional experienced in diagnosis and treatment of speech and feeding disorders.
Expectation that the member’s condition will improve from the services provided.

Background and Scope

Speech-language pathology services addressed by this policy encompass evaluation and treatment of impairments in articulation, fluency, voice, swallowing, and feeding. Pediatric feeding disorders are recognized as complex, multi-domain conditions that may involve medical, nutritional, feeding skill, and psychosocial dysfunction and can result in risks such as choking, pulmonary complications, or inadequate nutrition. Speech therapy is intended to diagnose and treat clinically significant communication or feeding/swallowing impairments rather than provide academic language instruction or services lacking demonstrated clinical benefit.

Key Definitions

inv-09: Pediatric feeding disorder definition — impaired oral intake not age-appropriate with associated dysfunctions

DefinitionImpaired oral intake that is not age-appropriate and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction (WHO ICF framework).

ScopeIncludes any aspect of eating or drinking (gathering/preparation, sucking, chewing, swallowing) and problems such as food refusal, disruptive mealtime behavior, rigid food preferences, suboptimal growth, or failure to master self-feeding skills.

Associated risksMay result in choking, pulmonary complications, inadequate nutrition/hydration, weight loss, and failure to thrive.

Complexity and comorbidityOften occurs with other medical, developmental, or behavioral problems and may involve oral-motor, swallowing, behavioral, and sensory issues.

Framework/sourceWorld Health Organization ICF definition cited to link feeding impairment with medical, nutritional, feeding skill, and psychosocial dysfunction.

Policy Summary

Payerselect_health

PolicySpeech therapy

Policy CodePolicy CCP.1302

Change TypeNo material change

Effective DateJun 1, 2025

Last ReviewDec 1, 2025

Next Review DateApr 1, 2027

SourceLink

On This Page

Step Therapy

Alternative in‑network evaluation and management

Before referring to externally contracted services, consider routine in‑network evaluation and management by the member’s PCP or specialists (including specialty therapists) who work in the area of speech, fluency, or swallowing disorders as covered alternative services.

Routine in‑network evaluation and management by primary care physicians.
In‑network specialists and specialty therapists experienced in speech, fluency, or swallowing disorders.

Documentation Required

Required documentation and provider qualifications

Submit a care plan and supporting objective evidence: the plan must state the type, amount, duration, frequency of therapy, and clearly defined measurable therapeutic goals. Documentation must include objective standardized testing or clinical assessment demonstrating impairment or pediatric feeding disorder, and identify that services will be provided by a trained, licensed professional experienced in diagnosis/treatment of speech and feeding disorders.

Care plan with type, amount, duration, frequency, and measurable goals.
Objective standardized testing or clinical assessment showing impairment or pediatric feeding disorder.
Provider qualifications: trained, licensed healthcare professional experienced in diagnosis/treatment of speech and feeding disorders.

Denial Risk

Denial risks — services lacking evidence or defined benefit

Do not request coverage for services that lack evidence of improved outcomes or a defined benefit in state/federal policy; such services may be denied. Examples include therapy for academic goals (grammar, vocabulary, reading), therapy delivered in a language other than the member’s home language, voice therapy for gender reassignment absent a functional limitation, and therapy when the member can feed/swallow adequately to maintain nutrition/hydration/pulmonary status or manage oral/pharyngeal secretions.

Speech therapy for academic goals (grammar, vocabulary, reading).
Therapy administered in a language other than the member’s language at home.
Voice therapy for gender reassignment without a functional limitation.
Therapy when member can feed/swallow to maintain adequate nutrition, hydration, and pulmonary status or manage oral/pharyngeal saliva accumulations.

inv-10: Speech disorder definition — impairment of articulation, fluency, or voice

DefinitionImpairment of the articulation of speech sounds, fluency, or voice (American Speech-Language-Hearing Association).

EvaluationAssessment includes clinical examination and age-appropriate standardized tests with standard scores designed to identify speech deficits and fluency difficulties; serial measurements may be used during therapy.

EtiologyMay be congenital/developmental or result from insult to auditory organs or the brain; can be organic (motor/neurologic, structural, sensory) or functional (idiopathic).

Treatment focusSpeech therapy interventions target speech/language production, voice, swallowing function, cognitive-linguistic skills, and general communication abilities using individualized behavioral approaches.