Speech and Hearing Disorders—Definitions

PURPOSE: This rule defines certain terms to ensure their uniform application in group health insurance and other designated cover- age. This rule is promulgated pursuant to section 376.781, RSMo. (1) The purpose of this rule is to set forth the terms and definitions which must be utilized in a policy, certificate, contract or plan document which provides speech and hearing benefits. (2) Definitions. For the purposes of this rule— (A) Loss or impairment of speech or hearing shall include communicative disorders resulting from genetic defects, birth defects, injury, illness, disease, developmental disabilities or delays or other causes whether of organic or nonorganic etiology and whether or not the person suffering from that loss or impairment had the capacity for speech, language or hearing before the loss or impairment occurred; (B) Necessary care and treatment shall include services to identify, assess, diagnose and consult about the need for treatment and to evaluate and monitor the effectiveness of treatment whether by instrumental, perceptional or standard procedures as well as the provision of treatment for any of the previously mentioned communicative disorders. These services shall include, but not be limited to: 1. Diagnostic and extended evaluation of hearing, which may include pure tone air conduction thresholds, speech thresholds, bone conduction thresholds, prediction of hearing loss from acoustic reflex, reflex eliciting auditory test, communication handicap inventories, word/sentence recognition tests and evoked potential monitoring and testing; 2. Determining range, nature and degree of hearing function related to a patient’s auditory efficiency; 3. Comprehensive behavioral evaluation for sensorineural site which includes advanced acoustic reflex tests, tests of auditory adaptation, tests of frequency discrimination and AND INSURANCE tests of intensity discrimination; 4. Testing, adjusting and evaluating auditory prosthetic devices which may include sound field tests, such as aided word/sentence recognition, real ear measures, warble tone thresholds, narrow band noise thresholds, and comfortable and uncomfortable loudness levels while wearing an auditory prosthesis; 5. Differentiation between organic and nonorganic hearing disabilities through evaluation of total response pattern and use of acoustic tests; 6. Planning, directing, conducting or participating in conservation, habilitative and rehabilitative programs including hearing aid selection and orientation, counseling, guidance, auditory training, speech reading, language habilitation and speech conservation; 7. Coordinating and consulting with educational, medical and other professional groups, and with patients and their families; 8. Diagnosing and evaluating speech and language competencies of individuals, including assessment of speech and language skills as related to educational, medical, developmental, social and psychological factors; 9. The services enumerated in paragraphs (2)(B)1.–8. shall be designed to evaluate and treat individuals to develop or utilize speech, language and other communicative skills to the maximum extent possible to remedy any loss or impairment for which services are being provided. However, nothing in this rule shall be construed to require services to improve public speaking, care of the professional voice or accent reduction; 10. Cognitive training secondary to open or closed head injury, regardless of cause; 11. Assisting individuals with voice disorders to develop proper control of the vocal and respiratory systems for correct voice production; 12. Evaluating and treating children with delayed or impaired speech or language disorders; 13. Determining the need for augmentative/prosthetic communication systems whether or not that system or that device replaces a body part. These systems or devices may include, but are not limited to, sign language, gesture systems, communication boards, electronic automated devices, mechanical devices, alaryngeal prosthesis, palatal prosthesis and synthetic voice systems; and 14. Planning, directing, or conducting habilitative and rehabilitative treatment programs to restore or provide communicative efficiency to individuals with communication problems of organic and nonorganic etiology, such as partial to total glossectomy, partial to total laryngectomy, or both; and (C) Other covered services shall mean any other medically necessary medical or health care services, or both, for which coverage is provided whether or not for acute conditions, provided while a patient in a hospital, or provided by or in a rehabilitation center, skilled nursing facility, clinic, home health agency or community-based program. This means that limitations on coverage may not be specific to speech, language and hearing disorders or for services rendered by speech language pathologists and audiologists. (3) The communicative disorders generally treated by speech/ language pathologists and audiologists shall include, but not be limited to, aphasia; motor speech disorders; delayed speech or language ability; total or partial speech or language loss or deficit; swallowing disorders; total or partial hearing loss or deficit; disorders of verbal and written language, articulation, voice, fluency, mastication, deglutition, cognition, auditory or visual processing and memory, and interactive communications; and disorders of air conduction, bone conduction, word/sentence recognition and acoustic impedance. AUTHORITY: sections 374.045 and 376.781.6, RSMo 1986.* Original rule filed March 25, 1991, effective Oct. 31, 1991. *Original authority: 374.045, RSMo 1967 and 376.781.6, RSMo 1984.