Speech therapy is considered medically necessary for restoring existing speech lost due to disease or injury. Therapy must be expected to restore the level of speech the participant had before the disease or injury. It is not covered for treatment of learning disabilities or birth defects. The plan maximum is 60 speech language pathology visits each calendar year. Certification through HCMU is required for members ages 17 and younger. Certification is not required for members ages 18 and older.
For charges incurred on or after Jan. 1, 2016, speech therapy services are also considered medically necessary for assessment and treatment of the diagnoses of pervasive developmental disorders (PDD) when the member meets any of the criteria listed below:
- Any loss of any language at any age;
- No two-word spontaneous (not just echolalia) phrases by 24 months;
- No babbling by 12 months;
- No gesturing (e.g., pointing, waving bye-bye) by 12 months; or
- No single words by 16 months.
A request for a speech therapy evaluation for members 17 and younger must include a copy of the prescription or referral from a physician with documentation of the diagnosis. Requests for subsequent speech therapy visits must include a treatment plan from the speech pathologist that lists specific measurable goals, and the expected amount, frequency and duration for therapy. There must be an expectation that the patient’s condition will improve significantly in a reasonable and predictable period of time. If at any point in the treatment it is determined that the expectations will not be met, services will no longer constitute covered speech language pathology services. If the patient’s response to treatment is determined to be insignificant or at a plateau, continued coverage of speech services are excluded.
For additional information, please contact the Health Care Management Unit.