Speech Therapy services are considered for payment when:
• They are prescribed or recommended by a doctor for the purpose of restoring or improving function in a patient with a physical impairment in phonation, due to illness, trauma, congenital anomaly or as a result of a therapeutic intervention, AND
• The patient is expected to achieve measurable improvement in a predictable and reasonable period of time (usually four to six months), AND
• Provide effective, specific and reasonable treatment for patient’s diagnosis and physical condition, AND
• They are provided according to a treatment plan, where changes in patient’s condition are evaluated, documented, and are certified by a doctor at least every thirty (30) days where the following is included:
The date of onset or exacerbation of the disorder/diagnosis;
The speech therapy evaluation;
Specific statements of long-term and short-term goals that are specific, quantifiable (measurable) and objective;
A reasonable estimate of when the goals will be reached;
The specific treatment techniques and/or exercises to be used in treatment; and
The frequency and duration of treatment, which must be medically necessary and consistent with generally accepted standards of practice for speech therapy.
• The speech therapy services provided must be of the complexity and nature to require that they are performed by a licensed speech-language pathologist; and
• Services that cannot be reasonably taught and implemented by a family member, and
• Do not duplicate services covered by any other type therapy being received.
Speech therapy often occurs in the school environment or in developmental language centers. Speech therapy is not covered for payment for any of the following conditions:
• Speech dysfunction that in itself is corrected alone, such as errors in articulation in children who are not related to a specific medical condition.
• Maintenance therapies aimed at preserving the present level of function and avoiding regression of that function, including services to maintain function using methods or procedures using routines, repetition or reinforcement.
• Procedures that can be effectively performed by family members, teachers, guardians/guardians or the patient himself.
• Developmental disorders not related to a medical condition, including but not limiting itself to:
Psychosocial language delay
Behavioral Disorders
Attention Deficit
Conceptual Disorders mental retardation developmental delay
Stuttering, babbling
Reduced cognitive function
