Covered Speech-Language Pathology and Audiology Services

Covered Speech-Language Pathology and Audiology Services A. The Division of Medicaid covers speech-language pathology and audiology services in the outpatient setting when medically necessary, ordered by a physician, physician assistant or nurse practitioner, for the diagnosis and treatment of a communication impairment and/or swallowing disorder due to disease, trauma, or congenital anomaly and prior authorized by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or a designated entity and the following requirements are met: 1. The services require the knowledge, skill and judgment of a state-licensed speech- language pathologist or audiologist. 2. The Certificate of Medical Necessity (CMN) for initial referral/order is completed by the prescribing provider prior to the speech-language pathology or audiology evaluation. 3. The plan of care (POC) is developed by a state-licensed speech-language pathologist or audiologist. 4. The prescribing provider approves the initial/revised POC with a signature and date: a) Before the initiation of treatment or change in treatment, or b) Within thirty (30) calendar days of the verbal order for the initial treatment plan or change in treatment. 5. The services are rendered as individualized speech language pathology or audiology services consistent with the symptomatology/diagnosis and do not exceed the beneficiary’s needs. 6. The services do not duplicate another provider’s services including those services provided in a school-based setting. 7. The beneficiary presents with one (1) or more of the following: a) Aphagia defined as an inability to swallow, b) Aphasia defined as an absence/impairment of the ability to communicate through speech, writing, or signs caused by focal damage to the language dominant hemisphere of the brain, c) Aphonia defined as an inability to produce sounds from the larynx due to excessive muscle tension, paralysis, or disease of the laryngeal nerves, d) Apraxia defined as an inability to form words to speak despite an ability to use facial and oral muscles to make sounds, e) Dysarthria defined as defective or difficult speech that involves disturbances in muscular control like weakness, lack of coordination, or paralysis of the speech mechanism, either oral, lingual, respiratory or pharyngeal muscles, resulting from damage to the peripheral or central nervous system, f) Dysphagia defined as difficulty swallowing, g) Dysphasia defined as language impairment from neurodevelopmental disorder or brain lesion, h) Dysphonia defined as difficulty speaking due to impairment of the muscles involving vocal production, and/or i) Vocal cord dysfunction defined as impairment of vocal cord mobility due to functional or structural abnormalities resulting from organic or neurological diseases. 8. Risk factors have been identified and documented including, but are not limited to: a) Neurological disorders/dysfunctions, such as hearing loss or cerebral palsy, b) Surgical procedures, such as partial/comprehensive/radical laryngectomy, repaired cleft palate, or glossectomy, c) Cognitive impairments that affect communication functions, or d) Medical conditions resulting in communication disorders that require restorative therapy including, but not limited to: 1) Laryngeal carcinoma requiring partial/total largyngectomy that results in dysphonia or aphonia, 2) Traumatic brain injury that may exhibit inadequate respiratory volume, apraxia, dysphagia, or dysarthria, 3) Progressive/static neurological conditions, such as amyotrophic lateral sclerosis, Parkinson’s disease, myasthenia gravis, multiple sclerosis, or Huntington’s disease, 4) Intellectual disability with disorders of dysarthria, dysphagia, apraxia, or aphagia, and/or 5) Cerebrovascular disease, such as cerebrovascular accident, presenting with apraxia, aphasia, dysphagia, or dysarthria. 9. The type of service requested includes one (1) or more of the following: a) Diagnostic and evaluation services: 1) To determine the type, causal factors, severity of speech-language or swallowing disorders, and the extent of service required to restore functions of speech, language, voice fluency, and swallowing, or 2) The beneficiary demonstrates changes in functional speech or remission of a medical condition that previously contradicted speech-language therapy. b) Therapeutic services defined as services requiring active corrective/restorative therapy, for communication disorders that result from: 1) Laryngeal carcinoma requiring partial/total largyngectomy that results in aphonia so the beneficiary can develop new communication skills through esophageal speech or the use of an electrolarynx, 2) Cerebrovascular disease, such as cerebrovascular accident, presenting with apraxia, aphasia, dysphagia, or dysarthria, or 3) Medical and neurological conditions, like traumatic brain injury, Parkinson’s disease, or multiple sclerosis, exhibiting inadequate respiratory volume/control, aphonia, dysphagia, dysarthria, or dysphonia. B. The Division of Medicaid reimburses for covered speech-language pathology or audiology services provided by: 1. A state-licensed speech-language pathologist or audiologist. 2. A state-licensed speech-language pathologist or audiologist assisted by a state-licensed speech-language pathologist or audiologist assistant under direct, on-site supervision by a state-licensed speech-language pathologist or audiologist. a) The Division of Medicaid defines direct, onsite supervision as face-to-face oversight by a state-licensed speech-language pathologist or audiologist at regular intervals, congruent with the standards of the American Speech-Language-Hearing Association (ASHA) and does not include: 1) Contacts by telephone, 2) Contacts by pager, 3) Video conferencing, and/or 4) Any method not approved by the Division of Medicaid. b) The initial evaluation, POC, and discharge summary must be completed by a state-licensed speech-language pathologist or audiologist. 3. A state-licensed speech-language pathologist or audiologist assisted by a speech- language pathology or audiology student who is enrolled in an accredited speech- language pathology or audiology program while completing the clinical requirements necessary for graduation under direct, on-site supervision of a state-licensed speech- language pathologist or audiologist, referred to as student assisted speech-language pathology or audiology services. a) The Division of Medicaid defines direct, on-site supervision of a speech-language pathology or audiology student as the face-to-face oversight by a state-licensed speech-language pathologist or audiologist. b) The state-licensed speech-language pathologist or audiologist must be physically present and engaged in student oversight during the entirety of a therapy session such that the state-licensed speech-language pathologist or audiologist is considered to be providing the speech-language pathology or audiology service. C. The state-licensed speech-language pathologist or audiologist cannot supervise at the same time during the work day more than: 1. One (1) speech-language pathology or audiology student, 2. A total of four (4) state-licensed speech-language pathologist or audiologist assistants, or 3. One (1) speech-language pathology or audiology student and three (3) state-licensed speech-language pathologist or audiologist assistants.