A. Covered conditions. Payment for speech therapy is limited to
active treatment of the physical defects listed below.
1. Following a cerebrovascular accident (includes subarachnoid hemorrhage,
cerebral hemorrhage and cerebral aneurysm).
2. Post-craniotomy for abscess, intracranial hemorrhage or tumor; post-head
injuries; post-comatose conditions or post-meningitis, encephalitis or brain abscess;
post-hydrocephalus for the sequelae or residual of previous damage that is documented as
stable and under adequate control.
3. For congenital anomalites, such as cleft lip and cleft palate.
4. For a hearing loss. Hearing loss is defined as a loss greater than 25
decibels of the pure tone average of intensities at 1000, 2000 and 3000 hertz. Includes
developmental hearing loss, acquired hearing loss and hearing loss resulting from
documented chronic otitis media.
a. Developmental hearing loss is decreased hearing sensitivity with onset
before language is fully developed.
b. Acquired hearing loss is that decreased hearing sensitivity with onset after
language is fully developed.
5. For medically documented chronic middle ear effusion or recurrent, acute
otitis media during the formative years of speech (up through age 4 years) which, because
of its chronicity and duration during these years, is attributed to producing a delay in
either speech or language. Nonacute, nonrecurrent otitis media does not meet this
criterion.
6. Resulting from a theraputic process, such as vocal cord surgery,
laryngectomy or radiation therapy.
7. For vocal cord nodules, either in lieu of surgery, or as pre-operative
treatment.
B. Exclusions. Speech therapy is not covered when the speech problem is the
reult of or complicated by the following conditions:
1. Psychosocial speech delay (includes delayed language development).
2. Syndromes associated with diagnosed disorders attributed to perceptual and
conceptual dysfunctions (with the exception of hearing loss as contained in paragraph
A.4., above).
3. Mental retardation; Down's syndrome.
4. Attention deficit disorders. Includes associated behavior problems,
including impulsivity behavior; hyperkinetic and hypokinetic disorders; and minimal brain
dysfunction.
5. Educational or occupational deficits to include learning disabilities and
dyslexia.
6. Lisping or stuttering.
7. Bronchitis or laryngitis.
8. Developmental articulation disorders (DSM-III-R 315.39) and developmental
language disorders, expressive and receptive types (DSM-III-R 315.31).
9. Spina bifida.
10. Myelomeningocele.
11. Infantile autism.
12. Paraplegia; quadriplegia.
13. Myofunctional or tongue thrust therapy.
14. Paradoxic vocal cord motion in presumed asthmatics.
15. Any other condition not specifically addressed herein is also excluded.
C. Esophageal speech training. Esophageal speech training is covered when the
patient has had vocal cord surgery (laryngectomy) or radiation treatment.
D. Length of individual speech therapy sessions.
1. Patients five years of age and under: 30 minutes per individual speech
therapy session is generally considered medically appropriate.
2. Patients over five years of age: one hour per individual speech therapy
session is generally considered medically appropriate.
E. Group speech therapy. CHAMPUS payment may be made for group therapy when, in
the opinion of the attending or referring physician and the speech therapist, the patient
would derive significant benefit from the group therapy. Group speech therapy sessions
should generally be no longer than 90 minutes in duration.
F. Claims review.
1. Number of sessions. Speech therapy which extends beyond 30 individual or
group (or a combination of individual and group) sessions per year must be justified with
a report from the speech therapist which documents the goals of treatment and which
extablishes that the patient is making reasonable pregress toward those goals. Such claims
must be submitted to medical review for a determination that the treatment goals are
reasonable and that the patient can reasonabley be expected to achieve those goals.
Progress from speech therapy should be measured in terms of the patient's improvement in
relation to the specific treatment goals set at the outset of therapy. Documentation of
improvement must include formal record keeping, formal testing and formal graphing
(including base rate and percentage of increase or decrease).
2. Length of sessions. Speech therapy which exceeds the customary length as
incicated in paragraph 4 above must be justified with a report from the speech therapist.
3. Speech therapy for school-age children.
a. CHAMPUS benefits for speech therapy for school-age children (under the age
of 19) are payable only if the medically necessary services cannot be made reasonably
available by the public school system under the provisions of Public Law 94-142 or similar
state or local law.
b. The initial claim must be accompanied by documentation showing that the
necessary services have been requested from the public school system and the public school
system has made a determination regarding its capacity to meet the needs of the child.
4. When the school district effectively denies provision of speech therapy
services, benefits may be paid for services that are otherwise covered under CHAMPUS.
5. The Contractor shall obtain medical review of any case in which the school
district proposes to place the child on a waiting list for speech therapy or in which the
plan of treatment proposed by the school district differs from that prescribed by the
attending physician. If the Contractor's medical review staff is of the opinion that the
program of speech therapy proposed by the school is inadequate from the standpoint of
medical necessity, CHAMPUS benefits may be paid only if the plan of treatment proposed by
the attending physician is determined to be medically appropriate and if the care is
otherwise covered under CHAMPUS.
6. Requests for additional documentation. Additional documentation must be
obtained by the fiscal intermediary in any case where a determineation cannot otherwise be
made as to the reasonableness of the treatment program. Failure to provide sufficient
documentation will result in denial of the claim.