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Speech Therapy
10.06.01o

Policy

The provision of benefits for all services related to Speech Therapy is in accordance with the individual's benefit contract and varies by product and group. Therefore, individual member benefits must be verified. 

​State mandates do not automatically apply to all plans; therefore, individual benefits must be verified.

MEDICALLY NECESSARY

SPEECH THERAPY EVALUATION AND SERVICES RELATED TO SPEECH THERAPY
Speech therapy evaluation and services related to speech therapy that are within the scope of the member's benefit contract are considered medically necessary and, therefore, covered when all of the following criteria are met:
  • ​The services are prescribed by a professional provider. 
  • The evaluation is performed by a qualified speech/language pathologist who is licensed in the state where the services are being performed. 
    • The documentation submitted must include a current comprehensive diagnostic evaluation that was performed within 3 months of the requested start date of the therapy. (Note: refer to the Required Documentation section for more information.)
  • The services must be of such a complex nature that they can only be performed by a speech/language pathologist.
  • The condition must be such that there is a reasonable expectation that the services will bring about a significant improvement within a reasonable time frame, regardless of whether the individual has a coexisting disorder.
  • The services are provided in accordance with an ongoing plan of care specific to the diagnosis.
    • The plan of care should incorporate ongoing care and be updated at least weekly, or more frequently as treatment progresses and goals change or are met. Upon request, documentation must be made available to the Company to show measurable progress toward meeting the short- and long-term goals outlined in the plan of care.
    • The therapy is performed for a communication and/or swallowing disorder that is a resulting from disease, surgery, injury, congenital and developmental anomalies, or prior therapeutic processes. ​​
  • The amount, frequency, and duration of the services must be consistent with accepted standards of practice.
OR

  • The evaluation (assessment) and therapy is performed for a swallowing disorder (dysphagia) resulting from a condition such as, but not limited to,​ a CVA, regardless of whether a communication disorder also exists.
EVALUATION FOR PRESCRIPTION OF SPEECH-GENERATING DEVICES
  • The evaluation for the prescription of speech-generating devices includes the evaluation of the individual's language comprehension and production across modalities (written, spoken, gestural) and the ability of the individual to operate and effectively use a speech-generating device or aid. The evaluation may also include evaluation of motor skills and nonverbal communication strategies (e.g., words, pictures, and vocalizations).
SPEECH THERAPY RE-EVALUATION
  • A re-evaluation is the reassessment of the individual’s performance and goals, after a plan of care has been instituted. A re-evaluation is considered medically necessary and, therefore, covered when a significant improvement, decline, or change in the individual's condition occurs, or if it is requested by the Company to determine the medical necessity of ongoing intervention. A re-evaluation requires the same professional skill as evaluation. A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making professional judgment about continued care, modifying goals, and/or treatment or terminating services.
THERAPEUTIC SERVICES (PATIENT ADAPTATION AND TRAINING) FOR THE USE OF SPEECH-GENERATING DEVICES
  • Individual adaptation and training for the use of speech-generating devices includes the development of operational competence in using a speech-generating device or aids, including customizing the features of the device to meet the specific communication needs of each individual and providing opportunities for developing skills in all aspects of device use.
NOT MEDICALLY NECESSARY

Speech therapy services performed for reasons other than those listed above are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis or treatment of illness or injury. These conditions or situations include, but are not limited to, the following:
  • Psychosocial speech delay (psychosocial factors can be associated with delayed speech development. These factors include, but are not limited to, large family size, late birth order, twinship, bilingual background.)
  • Behavior/social problems (e.g., impulsive behavior, difficulty in initiating/maintaining a conversation)
  • Attention-deficit hyperactivity disorder (ADHD) 
  • Stammering and stuttering that was not caused by acquired brain injury
  • Programs that are primarily educational in nature or that support an academic program
  • Services that otherwise would not require the skills of a qualified speech/language pathologist such as treatments that maintain function by using routines and repetitions
    • Examples of these services include, but are not limited to, word drills for developmental articulation errors, computer-based programs, and procedures that may be performed by the individual, family, or caregivers.
  • Accent modification
  • Social or support groups (e.g., "stroke clubs" or "lost cord clubs")
  • Behavioral feeding issues (e.g., decreased food repertoire ["picky eater"]) when a swallowing disorder is not present or does not result in a medical condition (e.g., failure to thrive, delayed growth)​
The continued treatment of an individual when the maximum therapeutic goals of a treatment plan have been achieved and no additional functional improvement is apparent or expected to occur, sometimes referred to as maintenance therapy, is considered not medically necessary and, therefore, not covered because the provision of services ceases to be of therapeutic value.
EXPERIMENTAL/INVESTIGATIONAL

MYOFUNCTIONAL THERAPY (OROFACIAL MYOFUNCTIONAL THERAPY)
Myofunctional therapy (orofacial myofunctional therapy) is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

TRANSCUTANEOUS NEUROMUSCULAR ELECTRICAL STIMULATION (NMES) FOR THE TREATMENT OF DYSPHAGIA
Although the US Food and Drug Administration (FDA) has approved devices for transcutaneous NMES for the treatment of dysphagia, the Company has determined that the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature. Therefore, transcutaneous NMES for the treatment of dysphagia is considered experimental/investigational by the Company and not covered.

DUPLICATE THERAPY
When individuals are receiving both occupational and speech therapy, or speech therapy with different providers, the therapies must provide different treatments with separate treatment plans and goals in order for each to be covered and be separately reimbursed. Otherwise, the therapy is considered duplicate therapy, which is not medically necessary and, therefore, not covered.

BENEFIT CONTRACT EXCLUSIONS

COGNITIVE REHABILITATIVE THERAPY
Cognitive rehabilitative therapy is a benefit contract exclusion and is, therefore, not covered with the following exception:
  • When provided integral to other supportive therapies, such as, but not limited to, physical, occupational, and speech therapies in a multidisciplinary, goal-oriented, and integrated treatment program designed to improve management and independence following neurological damage to the central nervous system caused by illness or trauma (e.g., stroke, acute brain insult, encephalopathy)
BENEFIT LIMITATIONS

Limitations, frequency, and annual maximums may be applied and vary by product or by group. Individual member benefits must be verified, as speech therapy benefits vary by product and group.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Documentation must support the medical necessity for the performance of a speech therapy evaluation or re-evaluation. Routine performance of speech therapy evaluations or re-evaluations are subject to review by the Company.

When ongoing speech therapy treatment is being requested, documentation from the initial evaluation should include all of the following:
  • A diagnosis and description of the specific problem to be treated. This should include the specific body area(s) evaluated and include all conditions and complexities that may impact treatment. For example, a description should include the pre-morbid function, date of onset, and current level of function.
  • Objective measurements, preferably standardized patient assessment instruments, and/or outcomes measurement tools related to current functional status, when available and appropriate to the condition being evaluated.
  • Clinician's clinical judgments or subjective impressions that describe the current functional status of the condition being evaluated, when they provide further information to supplement measurement tools.
  • A prognosis for return to pre-morbid condition or maximum expected condition with expected time frame and measurable plan of care.
The medical record should include the plan of care that has been written and developed by the eligible professional provider. The plan of care must be established prior to the initiation of therapy and signed by the provider.

The plan of care should include the following information:
  • The individual's significant history
  • The individual's diagnoses that require therapy
  • Any related orders
  • The goals for therapy, which should be specific and measurable, and the expected potential for achievement, which should include the type, amount, duration, and frequency of therapy services
  • Any contraindications to a course of therapy
  • The individual's awareness and understanding of the diagnoses, prognoses, and goals of therapy
  • The development of a maintenance program while therapy is being provided
  • When appropriate, a summary of past therapies and the results that were achieved
Daily treatment notes should include the following information:
  • Date of treatment
  • Specific treatment provided
  • Response to treatment
  • Skilled ongoing reassessment of the individual’s progress towards established goals
  • Objective, measurable, and specific documentation of progress towards goals using consistent and comparable methods
  • Changes to plan of care or objective reasoning for why the individual has not progressed towards goals
  • Name and credentials of the treating clinician
BILLING REQUIREMENTS

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

To report services as part of a speech therapy plan, Modifier GN (Services delivered under an outpatient speech language pathology plan of care​) must be appended to the applicable procedure codes.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, speech therapy is covered under the medical benefits of the Company products when the medical necessity criteria listed in this medical policy are met. However, services that are identified in this policy as not medically necessary, experimental/investigational, or a benefit contract exclusion are not eligible for coverage or reimbursement by the Company.​

BILLING GUIDELINES​

Speech therapy sessions are service-based codes, not time-based codes. Therefore, these services are reported and reimbursed based on the service provided, not the duration of the service. Providers should report a single encounter with "1" as the unit of service, regardless of the duration of the service on a given day.

MANDATES

The laws of the state where the group benefit contract is issued determine the mandated coverage.

Speech therapy services may be available for coverage in accordance with the New Jersey State Mandate for Biologically Based Mental Illness, the Pennsylvania State Mandate for Autism Spectrum Disorders (ASD) and the Pennsylvania State Mandate for Stuttering. 

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the FDA for transcutaneous neuromuscular electrical stimulation for the treatment of dysphagia.

Description

SPEECH THERAPY

Speech therapy (speech/language pathology) services are services that are deemed necessary for the diagnosis and/or treatment of speech disorders, language disorders, and cognitive communication impairments that result in communication disabilities or dysphagia (swallowing disorder). Speech therapy is the medically prescribed treatment for speech and language disorders due to disease, surgery, injury, congenital anomalies (e.g., congenital hearing impairment), speech/language delay, or previous therapeutic processes that result in communication disabilities and/or dysphagia. Speech/language pathologists use a variety of modalities in the treatment of communication deficits and dysphagia, allowing for successful treatment outcomes.

Speech therapy services can be habilitative​ or rehabilitative. Habilitation therapy refers to healthcare services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech/language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. These services are provided by or under the supervision of an organized staff of professional providers.

Rehabilitation therapy consists of treatments designed to improve, maintain, and prevent the deterioration of skills and functioning for daily living that have been lost or impaired. These services are provided by or under the supervision of an organized staff of professional providers.

MYOFUNCTIONAL THERAPY FOR TEMPOROMANDIBULAR DISORDERS

Myofunctional therapy (e.g., orofacial myofunctional therapy [OMT]) is the treatment of an orofacial muscle imbalance, an incorrect swallowing pattern, temporomandibular joint muscle dysfunction syndrome, and/or tongue thrusting, bruxing, clenching, or sucking habits. Oral myofunctional therapy uses exercises and stimulation to increase awareness of oral and facial muscles and inhibit inappropriate oral behaviors and/or strengthen appropriate oral muscle functioning. This treatment implies metacognitve abilities of the individual, which include self-awareness and self-monitoring. Although the use of this treatment approach has yielded some positive results for some individuals exhibiting orofacial muscle imbalance, tongue thrusting and bruxing, the data collected thus far have been inconclusive regarding its true effectiveness.

Cai et al. (2010) evaluated the effectiveness of OMT on facial mimic muscles for individuals with incomplete peripheral facial injury. Ninety-two individuals with 241 injured branches of incomplete peripheral facial nerve injury were separated into a treatment and a control group and were followed for a range of 1 to 4 years. The treatment group consisted of 58 individuals. Outcome measurements included a House-Brackmann facial nerve grading system, a quantitative facial nerve function estimating system, and electroneurography. Based on these measurements, facial nerve injury was categorized as normal, minor, moderate, or severe. Among those with minor facial injury, there was no statistically significant difference in the time needed for initial recovery of nerve function following injury or for final recovery (i.e., time point after which no further improvement could be obtained) between the treatment and control groups. In the moderate and severe facial groups, both the initial recovery and final recovery was shorter for the OMT group than for the control group. The authors concluded that while OMT on facial mimic muscles may not shorten the recovery time for individuals with minor facial nerve injuries, it may accelerate the rate of recovery for individuals with moderate or severe facial injury.

De Félicio et al. (2010) evaluated the effectiveness of OMT on the treatment of individuals with associated articular and muscular temporomandibular disorders (TMD). Ten individuals were treated with OMT (T group), 10 individuals were treated with an occlusal splint (OS group), and 10 individuals were untreated (control group). Additionally, there were 10 individuals without TMD who represented asymptomatic individuals. Outcome measurements included Helkimo Clinical Dysfunction Index symptom scores, frequency and severity of signs and symptoms, and orofacial myofunctional evaluation. The authors determined that individuals treated with OMT presented better results and had a statistically significant improvement when compared with those treated with an occlusal splint. The study is limited by its small sample size, particularly when considering the number of stratifications created by the authors for intergroup comparisons.

Ferreira et al. (2011) evaluated the available scientific literature on the effectiveness of OMT for the treatment of oral myofunctional disorders. Of 108 studies identified and published between 2000 and 2010, 38 were chosen for inclusion in the review. The included studies were primarily retrospective case series and literature reviews. The authors concluded that there was a lack of knowledge about the effects of myofunctional exercises used by clinicians. Additionally, there was a lack of scientific evidence about appropriate treatment protocols and indications for use.

Van Dyck et al. (2015) investigated the effects of OMT on tongue behavior in children with anterior open bite (AOB) and a visceral swallowing pattern. The study included 22 individuals aged between 7 and 10 years. Functional characteristics, including tongue posture at rest, swallowing pattern and articulation, and presence of AOB were measured at the beginning of treatment, at the end of treatment, and 6 months after treatment. The authors determined that OMT did change tongue elevation strength, tongue posture at rest, and tongue position during swallowing of solid food. Articulation of /s,l,n,d,t/ was not improved by OMT. The authors concluded that OMT can positively influence tongue behavior; however, further research is recommended to clarify the success of OMT as an adjunct to orthodontic treatment and to identify possible factors influencing the outcome.

The current available peer-reviewed literature and scientific evidence is insufficient in both quality and quantity to permit conclusions regarding the safety and effectiveness of OMT. Some studies indicate that there may be symptom improvement in a select patient population. However, the majority of the available literature consists of case series with small sample size and short-term follow-up. Larger randomized controlled trials with appropriate follow-up and validated comparative control groups are necessary to determine the safety and effectiveness of OMT.

TRANSCUTANEOUS NEUROMUSCULAR ELECTRICAL STIMULATION (NMES) THERAPY FOR DYSPHAGIA

 Devices such as VitalStim Plus​ involve electrotherapy treatment that is used by licensed healthcare providers, including speech therapists, for treating individuals who have dysphagia due to any nonmechanical cause. VitalStim therapy is a specialized type of NMES in which a small current is passed through external electrodes on the neck to stimulate inactive or atrophied swallowing muscles. With repeated therapy, throat muscles are said to be retrained. However, based on review of the scientific and clinical literature, the clinical efficacy and utility of this service remains unproven.

In 2007, Carnaby-Mann and Crary conducted a meta-analysis aimed at evaluating the effect of transcutaneous NMES on swallowing rehabilitation. The authors identified seven publications (two were controlled studies) that met inclusion/exclusion criteria, with a total patient population of 225 with swallowing difficulty from numerous etiologies (e.g., stroke, cancer). Clinical swallowing scale was the only health outcome metric used across all included studies. Treatment protocols varied in length from 1 to 24 weeks, in total number of treatment sessions, and in regard to reporting of electrode placement. The authors reported a significant effect size with significant heterogeneity. Removal of two outlier trials rendered heterogeneity nonsignificant, although statistical testing supporting the classification of these trials as outliers was not presented. Based on the aforementioned results, the authors concluded that this preliminary meta-analysis revealed a small but significant summary effect size for transcutaneous NMES for swallowing and noted the small number of studies and low methodological grading for these studies. The large methodological differences between study protocols and outcome measurements and NMES treatment methodologies precludes the discernment of any reliable conclusions from these data.

Ryu et al. (2008) published the results from a prospective, randomized, double-blinded case-control study aimed at evaluating the effect of NEMS (VitalStim) on dysphagia following treatment for head and neck cancer. The study randomly assigned 14 individuals to 30 minutes of NMES and 30 minutes of traditional swallowing training for 5 days per week for 2 weeks, with 12 individuals randomly assigned to sham stimulation plus traditional swallowing training. Functional changes assessed by the clinical dysphagia scale (CDS), the functional dysphagia scale (FDS), the American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) and the M.D. Anderson dysphagia inventory (MADI) were the main outcomes assessed before and after treatment. The authors reported that average changes of FDS score were 11.4 ± 8.1 for the experimental group and 3.3 ± 14.0 for the control group. No significant results were observed with regard to CDS, ASHA NOMS, and MADI scales. While noting limitations including but not limited to small sample size, participants lost to follow-up, and heterogeneity within study population, the authors concluded that the results suggest that the combination of electrical stimulation and conventional rehabilitation treatment is superior to conventional rehabilitation treatment alone in those suffering from dysphagia following treatment for head and neck cancer.

Lin et al. (2009) published results from a comparative study intended to assess the effectiveness of functional electrical stimulation (FES) (VitalStim) in comparison to a home rehabilitation program (HRP). The study enrolled 20 individuals with nasopharyngeal carcinoma. FES treatment consisted of 15 60-minute sessions of stimulation one to three times per week. The FES electrodes were placed above the hyoid bone and between the hyoid bone and thyroid cartilage to stimulate the suprahyoid muscles. HRP subjects were instructed to perform twice-daily strengthening exercises and repeat each item more than 10 times during each session with follow-up every 2 weeks. Outcomes related to quality of life, the penetration–aspiration scale (PAS), the movement of the hyoid bone, and the amount of pyriform sinuses stasis were assessed before and after treatment. The authors observed improvements in quality of life, the duration of the movement of thin barium through the hyoid, and speed of paste barium through the hyoid. The pyriform sinus stasis area of the paste barium reached significant difference within the FES group. Conversely, no improvements in swallowing outcomes were reported in the HRP group. Also, the reported degree of improvement in the movement speed of the thin barium and the PAS of the paste barium were statistically significantly greater in the FES group than in the HRP group. Based on these results, the authors concluded that FES will improve the swallowing function of individuals with nasopharyngeal carcinoma with dysphagia and bring about better quality of life. While acknowledging a few limitations, the authors neglected to address the full limitations of a small sample size, its impact on statistical power, and the large probability for type II statistical error. Additional methodological flaws were also not addressed, including the lack of a statistical adjustment (e.g., a Bonferroni correction) commonly applied to the alpha value (P value) when making multiple comparisons.

In 2009, Permsirivanich et al. published results from a randomized controlled trial that compared outcomes between NMES (VitalStim) and rehabilitation swallowing therapy (RST). The study randomly assigned 23 individuals with stroke and persistent dysphagia to receive NMES or RST 11 for 4 weeks or until they reached functional oral intake scale (FOIS) level 7 (i.e., total oral diet with no restrictions). Outcomes were assessed as changes in functional oral intake (FOI), complications associated with therapy, and number of therapy sessions. The authors reported an improvement in FOI by at least one unit compared with the prior-to-therapy score in 91.3% of all participants, 90.91% in the RST group, and 91.67% in the NMES group. Also, a statistically significant difference in average changes in FOIS scores was also observed between groups.

The authors noted the positive effects of both treatments on persistent dysphagia while also calling for further investigation into the effects of NMES on specific biomechanical aspects of pharyngeal swallowing, as well as the best location for electrode adhesion, effects of varying frequencies and amplitude of electrical stimulation on swallowing physiology, duration of each session, total number of sessions due to the variable responses among individuals, and the need for larger studies to validate study results.

Xia et al. (2011) conducted a randomized controlled three-armed trial intended to evaluate the effects of VitalStim therapy coupled with conventional swallowing training on the recovery of individuals who had dysphagia post-stroke. The study randomly assigned 120 participants to one of three treatment arms: conventional swallowing therapy group, VitalStim therapy group, and VitalStim therapy plus conventional swallowing therapy group. Data regarding swallowing function (assessed by the Standardized Swallowing Assessment [SSA] and Videofluoroscopic Swallowing Study [VFSS] tests), swallowing-related quality of life (assessed by the SWAL-QOL questionnaire), and signals of surface electromyography (sEMG) of swallowing muscles were recorded prior to and following 4 weeks of treatment. Improvements in all treatment arms were observed following treatment in regard to functional and quality of life outcomes when compared to baseline. Intergroup comparisons of outcomes following treatment illustrated that combination therapy significantly improved outcome metrics over conventional therapy or VitalStim therapy alone. As noted in previous trials, no significant differences were found between the conventional swallowing therapy group and the VitalStim therapy group. Based on these results, the authors concluded that VitalStim therapy coupled with conventional swallowing training was conducive to recovery of post-stroke dysphagia, although the authors noted that studies evaluating the long-term effects of the both single and combination therapy methods are needed.

In 2011, Christiaanse et al. published results of a controlled study comparing the change in swallowing function in pediatric individuals with dysphagia who received NMES to a control group who received oral motor training and dietary manipulation without NMES. Children were classified into two groups based on the etiology of their dysphagia: acquired versus primary. The authors concluded that NMES treatment of anterior neck muscles in a heterogeneous group of pediatric individuals with dysphagia did not show more improvement in swallowing function than those who did not receive NMES treatment; however, there may be subgroups of children that would improve with NMES treatment.

Bhatt et al. (2015) conducted a controlled study investigating the role of transcutaneous NMES (tNMES) therapy in maintaining swallowing function during chemoradiotherapy treatments for locally advanced head and neck cancer. The study consisted of 43 individuals with locally advanced head and neck cancer treated with TNMES compared to a control group of 55 individuals not treated with TNMES therapy. Validated swallowing scale scores were assigned. All individuals' swallowing scores decreased postchemoradiotherapy. A difference in the mean decline in scores for the control group versus the treatment group using the FOIS was seen, favoring tNMES intervention 23% to 7%. The authors concluded that tNMES can be considered an adjunct to dysphagia reduction in individuals with locally advanced head and neck cancer; however, further studies are needed to define the benefit of tNMES intervention.

Sun et al. (2020) evaluated the effects of transcutaneous NMES on swallowing disorders through a systematic review and meta-analysis. Eight RCTs and three quasi-RCTs were included. These studies demonstrated a significant, moderate pooled effect size (standard mean difference [SMD], 0.62; 95% confidence interval [CI], 0.06–1.17). Studies stimulating suprahyoid muscle groups revealed a negative SMD of 0.17 (95% CI, −0.42 to 0.08), whereas large effect size was observed in studies stimulating the infrahyoid muscle groups (SMD, 0.89; 95% CI, 0.47–1.30) and stimulating the suprahyoid and infrahyoid muscle groups (SMD, 1.4; 95% CI, 1.07–1.74). Stimulation lasting 45 minutes or less showed a large, significant pooled effect size (SMD, 0.89; 95% CI, 0.58–1.20). The quality of evidences was rated as low to very low. There is no firm evidence to conclude on the efficacy of neuromuscular electrical stimulation on swallowing disorders. Larger scale and well-designed RCTs are needed to reach robust conclusions.​​

Miller et al. (2022) reviewed the effectiveness of neuromuscular electrical stimulation in the treatment of dysphagia through a systematic review. Eighteen studies were identified with varying patient groups, stimulation protocols, electrode placement, and therapy settings. However, 16 studies have reported beneficial outcomes in relation with NMES. The purpose of this systematic review was to evaluate the most recent studies regarding a potential effectiveness of NMES as a treatment for oropharyngeal dysphagia considering different aspects. It could generally be concluded that there is a considerable amount of level 2 studies suggesting that NMES is an effective treatment option when combined with TDT for individuals with dysphagia after stroke and individuals with Parkinson disease or with different kinds of brain injuries leading to dysphagia. Up to date, not a single study has investigated or better defined the most effective NMES and therapy parameters, although it is hypothesized that adequate protocols represent a key factor in the effectiveness of NMES therapy. A clear therapy suggestion concerning therapy parameters or therapy frequency can therefore not be derived from this systematic review.​ Further research is still necessary in order to clarify which stimulation protocols, parameters, and therapy settings are most beneficial for certain patient groups and degrees of impairment.​​

Wang et al. (2023) evaluated the effects of transcutaneous NMES on post-stroke dysphagia through a systematic review and meta-analysis of RCTs. Forty-six RCTs were included in the meta-analysis. The meta-analysis showed that NMES combined with routine ST could effectively increase the forward and upward movement distance of the hyoid bone, improve the quality of life of individuals with post-stroke dysphagia, reduce the rate of complications, and promote the recovery of swallowing function. NMES with a frequency of 25 Hz, an intensity of 0 to 15 mA, and a treatment course of 4 weeks or less may have better results. Individuals with an onset of fewer than 20 days and over 60 years old appear more effective with NMES plus ST. However, the authors concluded that there is insufficient evidence on the safety of NMES plus ST for post-stroke dysphagia. Moreover, due to the small number of included literature and the low quality of evidence, more large-sample, high-quality, multicenter RCT studies are needed to prove the clinical efficacy of NMES plus ST in the treatment of post-stroke dysphagia.​​

References

American Speech-Language-Hearing Association (ASHA). 2023 ICD-10-CM diagnosis codes related to speech, language, and swallowing disorders. [ASHA Web Site]. 2025. Available at: https://www.asha.org/uploadedFiles/ICD-10-Codes-SLP.pdf. Accessed June 19, 2025. 

American Speech-Language-Hearing Association (ASHA). Speech-Language Pathology Medical Review Guidelines. [ASHA Web Site].​ 2015. Available at: Speech-Language Pathology Medical Review Guidelines. Accessed July 15, 2025. 


American Speech-Language-Hearing Association (ASHA). Accent modification. [ASHA Web site]. 2025. Available at: http://www.asha.org/public/speech/development/accent-modification/. Accessed June 19, 2025. 


American Speech-Language-Hearing Association (ASHA). Autism (practice portal). Available at: www.asha.org/Practice-Portal/Clinical-Topics/Autism/. Accessed June 19, 2025. ​


American Speech-Language-Hearing Association (ASHA). New and revised speech language pathology ICD-10-CM codes for 2024. [ASHA Web Site]. 2025. Available at: https://www.asha.org/Practice/reimbursement/coding/New-and-Revised-ICD-10-CM-Codes-for-SLP/. Accessed June 19, 2025. ​​

American Speech-Language-Hearing Association (ASHA). Pediatric Feeding and Swallowing. [ASHA Web site]. 20025. Available at: Pediatric Feeding and Swallowing (asha.org). Accessed June 19, 2025. 

American Speech-Language-Hearing Association (ASHA). Stuttering and Cluttering. [ASHA Web site]. 2025. Available at: http://www.asha.org/public/speech/disorders/stuttering.htm. Accessed June 19, 2025. ​​

Andrade CR, Juste FS. Systematic review of delayed auditory feedback effectiveness for stuttering reduction. J Soc Bras Fonoaudiol. 2011;23(2):187-191.

Bhatt AD, Goodwin N, Cash E, et al. Impact of transcutaneous neuromuscular electrical stimulation on dysphagia in patients with head and neck cancer treated with definitive chemoradiation. Head Neck. 2015;37:1051-1056.


Bothe AK, Davidow JH, Bramlett RE, Ingham RJ. Stuttering treatment research 1970-2005: I. Systematic review incorporating trial quality assessment of behavioral, cognitive, and other approaches. Am J Speech Lang Pathol. 2006;15(4):321-341.​


Cai ZG, Shi XJ, Lu XG, et al. Efficacy of functional training of the facial muscles for treatment of incomplete peripheral facial nerve injury. Chin J Dent Res. 2010;13(1):37-43.

Cantwell DP, Baker L. Assessment. In: Developmental Speech and Language Disorders. New York, NY: Guilford Press; 1987:42.

Carter J, Musher K. Evaluation and treatment of speech and language disorders in children. [UpToDate Web site]. 04/08/2025. Available at: http://www.uptodate.com [via subscription only]. Accessed June 19, 2025. ​


Cayley AS, Tindall AP, Sampson WJ, Butcher AR. Electropalatographic and cephalometric assessment of myofunctional therapy in open-bite subjects. Aust Orthod J. 2000;16(1):22-33.

Christiaanse ME, Mabe B, Russell G, et al. Neuromuscular electrical stimulation is no more effective than usual care for the treatment of primary dysphagia in children. Pediatr Pulmonol. 2011;46:559-565.


Clark DG. Aphasia: prognosis and treatment. [UpToDate Web site]. 11/21/2022. Available at: http://www.uptodate.com. Accessed February 20, 2024. 

Carnaby-Mann GD, Crary MA. Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. Arch Otolaryngol Head Neck Surg. 2007;133(6):564.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 170.3: Speech-language pathology services for the treatment of dysphagia. [CMS Web site]. 10/01/2006. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCD​Id=192&ncdver=2&bc=AgAAgAAAAAAAAA==&. Accessed June 19, 2025. 

Christensen M, Hanson M. An investigation of the efficacy of oral myofunctional therapy as a precursor to articulation therapy for pre-first grade children. J Speech Hear Disord. 1981;46(2):160-165.

Company Benefit Contracts.

De Félicio CM, Freitas RL, Bataglion C. The effects of orofacial myofunctional therapy combined with an occlusal splint on signs and symptoms in a man with TMD-hypermobility: case study. Int J Orofacial Myology. 2007;33:21-29.

De Felício CM, de Oliveira MM, da Silva MA. Effects of orofacial myofunctional therapy on temporomandibular disorders. Cranio. 2010;28(4):249-259.

Ferreira TS, Mangilli LD, Sassi FC, et al. Speech and myofunctional exercise physiology: a critical review of literature. J Soc Bras Fonoaudiol. 2011;23(3):288-296.

Forrest K. Are oral-motor exercises useful in the treatment of phonological/articulatory disorders. Semin Speech Lang. 2002;23(1):15-26.

Foundas AL, Mock JR, Corey DM, et al. The SpeechEasy device in stuttering and nonstuttering adults: fluency effects while speaking and reading. Brain Lang. 2013;126(2):141-150.

Gallop RF, Runyan CM. Long-term effectiveness of the SpeechEasy fluency-enhancement device. J Fluency Disord. 2012;37(4):334-343.
​
Hauner KKY, Shriberg LD, Kwiatkowski J, Allen CT. A subtype of speech delay associated with developmental psychosocial involvement. J Speech Lang Hear Res. 2005;48(3):635-650.


Kiger M, Brown CS, Watkins L. Dysphagia management: an analysis of patient outcomes using VitalStim therapy compared to traditional swallow therapy. Dysphagia. 2006;21(4):243-253.

Lin P-H, Hsiao T-Y, Chang Y-C, et al. Effects of functional electrical stimulation on dysphagia caused by radiation therapy in patients with nasopharyngeal carcinoma. Support Care Cancer. 2011l;19(1):91-99.

Lincoln M, Packman A, Onslow M. Altered auditory feedback and the treatment of stuttering: A review. J Fluency Disorders. 2006;31:71-89.

Loo J, Bamiou D, Campbell N, Luxon L. Computer-based auditory training (CBAT): benefits for children with language- and reading-related learning difficulties. Dev Med Child Neurol. 2010;52:708-717.

Mason RM. A retrospective and prospective view of orofacial myology. Int J Orofacial Myology. 2008;34:5-14.


Miller S, Peters K, Ptok M. Review of the effectiveness of neuromuscular electrical stimulation in the treatment of dysphagia - an update. Ger Med Sci. 2022;20:Doc08.​

Nam-Jong P. Dysphagia. [e-Medicine Web Site]. 05/07/2024. Available at: http://www.emedicine.com/pmr/topic194.htm. Accessed June 19, 2025. 

National Institute on Deafness and Other Communication Disorders (NIDCD). Stuttering. [NIDCD Web site]. 03/06/2017. Available at: http://www.nidcd.nih.gov/health/voice/Pages/stutter.aspx. Accessed June 19, 2025. ​


New Jersey Annotated Statutes. Title 17 Corporations and institutions for finance and insurance. Subtitle 3: Insurance. Part 9: Hospital and medical service corporations, etc. Chapter 48E: Health service corporations. Coverage for audiology and speech-language pathology services. West Group. 2002. Current through L.2002, c.44. 17:48E-35.17.

New Jersey Permanent Statutes. Title 17B Insurance. 17B:26-2.1p Health insurance policy to cover certain audiology, speech-language pathology services. L.1997, c.419, s.4.

New Jersey Permanent Statutes. Title 17B Insurance. 17B:27-46.1s. Group health insurer to cover certain audiology, speech-language pathology services. L.1997, c.419, s.5.

Novitas Solutions, Inc. Local Coverage Article A54111. Billing and Coding: Speech language pathology (SLP) services: communication disorders. [Novitas Solutions, Inc. Web site]. 01/01/2025. Available at: Article - Billing and Coding: Speech Language Pathology (SLP) Services: Communication Disorders (A54111). Accessed June 19, 2025. 


Novitas Solutions, Inc. Local Coverage Determination (LCD) L35070: Speech-language pathology (SLP) services: communication disorders. [Novitas Solutions, Inc. Web site]. 10/01/2015. Revised 08/13/2020. Available at: LCD - Speech - Language Pathology (SLP) Services: Communication Disorders (L35070) (cms.gov)​. Accessed June 19, 2025. 


​Pennsylvania (PA) General Assembly. PA Insurance Company Law of 1921. Act 62 of 2008. H1150;§635.2: Autism Spectrum Disorders Coverage; signed July 9, 2008. [PA General Assembly Web site]. Available at: 2008 Act 62 - PA General Assembly (state.pa.us). Accessed June 19, 2025. 


Pennsylvania (PA) General Assembly. PA Insurance Company Law of 1921.  Act 104 of 2024. Speech Therapy for Stuttering; signed October 16, 2024.  ​[PA General Assembly Web site]. Available at: Act No. 104 of 2024 - The Official Website of the Pennsylvania General Assembly​. Accessed June 19, 2025. ​


Permsirivanich W, Tipchatyotin S, Wongchai M, et al. Comparing the effects of rehabilitation swallowing therapy vs. neuromuscular electrical stimulation therapy among stroke patients with persistent pharyngeal dysphagia: a randomized controlled study. J Med Assoc Thai. 2009;92(2):259.

Pollard R, Ellis JB, Finan D, Ramig PR. Effects of the SpeechEasy® on objective and perceived aspects of stuttering: a six-month, phase I clinical trial in naturalistic environments. J Speech Lang Hear Res. 2009;52(2);516-533.

Powell TW. An integrated evaluation of nonspeech oral motor treatments. Lang Speech Hear Serv Sch. 2008;39(3):422-427.

Ray J. Functional outcomes of orofacial myofunctional therapy in children with cerebral palsy. Int J Orofacial Myology. 2001;27:5-17.

Ryu JS, Kang JY, Park JY, et al. The effect of electrical stimulation therapy on dysphagia following treatment for head and neck cancer. Oral Oncol. 2009;45(8):665-668.

Shaw GY, Sechtem PR, Searl J, et al. Transcutaneous neuromuscular electrical stimulation (VitalStim) curative therapy for severe dysphagia: myth or reality? Ann Otol Rhinol Laryngol. 2007;116(1):36-44.

SpeechEasy®. SpeechEasy® is Stuttering Management. [SpeechEasy® Web site]. 2019. Available at: http://www.speecheasy.com/. Accessed June 19, 2025. 


Sun Y, Chen X, Qiao J, et al. Effects of Transcutaneous Neuromuscular Electrical Stimulation on Swallowing Disorders: A Systematic Review and Meta-Analysis. Am J Phys Med Rehabil. 2020;99(8):701-711.​

US Food and Drug Administration (FDA). Centers for Devices and Radiological Health (CDRH). eSWALLOW™ Dysphagia Therapy Unit. 510(k) summary. [FDA Web site]. 02/10/2011. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf9/K092202.pdf. Accessed June 19, 2025. 

US Food and Drug Administration (FDA). Centers for Devices and Radiological Health (CDRH). Guardian Dysphagia dual channel NMES unit. 510(k) summary. [FDA Web site]. 02/07/2013. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf12/K120922.pdf. Accessed June 19, 2025. 

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. VitalStim® Experia. 510(k) summary. [FDA Web site]. 06/11/2007. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf7/K070425.pdf. Accessed June 19, 2025.  

US Food and Drug Administration (FDA). Centers for Devices and Radiological Health (CDRH). VitalStim® Plus Electrotherapy System. 510(k) summary. [FDA Web site]. 02/08/2016. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf15/k153224.pdf. Accessed June 19, 2025. 

US Food and Drug Administration (FDA). Centers for Devices and Radiological Health (CDRH). Vitalstim-Experia. 510(k) summary. [FDA Web site]. 06/11/2007. Available at:https://www.accessdata.fda.gov/cdrh_docs/pdf7/K070425.pdf. Accessed June 19, 2025. ​

Van Dyck C, Dekeyser A, Vantricht E, et al. The effect of orofacial myofunctional treatment in children with anterior open bite and tongue dysfunction. Eur J Orthod. 2016;38(3):227-234.

VitalStim® Therapy. VitalStim® Plus. [DJO Global/VitalStim® Web site]. Available at: http://www.djoglobal.com/vitalstim. Accessed June 19, 2025. 


Wang Y, Xu L, Wang L, et al. Effects of transcutaneous neuromuscular electrical stimulation on post-stroke dysphagia: A systematic review and meta-analysis. Front Neurol. 2023;14:1163045.​ Available at: Frontiers | Effects of transcutaneous neuromuscular electrical stimulation on post-stroke dysphagia: a systematic review and meta-analysis​. Accessed March 13, 2025. ​​

Xia W, Zheng C, Lei Q, et al. Treatment of post-stroke dysphagia by vitalstim therapy coupled with conventional swallowing training. J Huazhong Univ Sci Technolog Med Sci. 2011;31:73-76.

Coding

CPT Procedure Code Number(s)
92507, 92508, 92521, 92522, 92523, 92524, 92526, 92607, 92608, 92609, 92610, 97129, 97130
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
Report the most appropriate diagnosis code in support of medically necessary criteria as listed in the policy.​
HCPCS Level II Code Number(s)
G0153 Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes

G0161 Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language therapy maintenance program, each 15 minutes

S9128 Speech therapy, in the home, per diem

S9152 Speech therapy, re-evaluation
Revenue Code Number(s)
​0440 Speech Therapy Language Pathology-General Classification

0441 Speech Therapy Language Pathology-Visit Charge

0442 Speech Therapy Language Pathology-Hourly Charge

0443 Speech Therapy Language Pathology-Group Rate

0444 Speech Therapy Language Pathology-Evaluation or Reevaluation

0449 Speech Therapy Language Pathology-Other Speech Therapy​

0979 Professional Fees (Extension of 096X)-Speech Pathology

Modifiers

TO REPORT SPEECH THERAPY SERVICES, APPEND THE FOLLOWING MODIFIER:

GN Services delivered under and outpatient speech language pathology plan of care 

TO REPORT HABILITATION OR REHABILITATION SERVICES, APPEND THE FOLLOWING MODIFIERS:

96 Habilitative Services

97 Rehabilitative Services

Coding and Billing Requirements

Policy History

Revisions From 10.06.01o:
01/01/2026
​This version of the policy will become effective 01/01/2026.

The intent of this policy remains unchanged; however, the policy criteria for Speech Therapy Evaluation and Services Related to Speech Therapy has been revised to clarify that the services are prescribed by a professional provider and the therapy is performed for a communication and/or swallowing disorder that is a resulting from disease, surgery, injury, congenital and developmental anomalies, or prior therapeutic processes. 

In addition, the following disclaimer was added to the policy:
The provision of benefits for all services related to Speech Therapy is in accordance with the individual's benefit contract and varies by product and group. Therefore, individual member benefits must be verified. ​
​​​
The Guidelines section of the policy has been revised to include the following statement regarding State Mandates:

Speech therapy services may be available for coverage in accordance with the New Jersey State Mandate for Biologically Based Mental Illness, the Pennsylvania State Mandate for Autism Spectrum Disorders (ASD) and the Pennsylvania State Mandate for Stuttering. 

Revisions From 10.06.01n:
03/24/2025
​This version of the policy will become effective 03/24/2025.

The intent of this policy remains unchanged; however, the policy has been updated to communicate that the speech therapy evaluation is performed by a qualified speech/language pathologist who is licensed in the state where the services are being performed. ​

Revisions From 10.06.01m:
07/01/2024
​The version of this policy will become effective 07/01/2024.

The intent of this policy remains unchanged; however, the policy has been updated to incorporate information from medical policy #07.03.03h Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD), which will be archived on 07/15/2024. ​

In addition, a billing requirement was added ​to append the GN modifier when reporting speech therapy services. ​​

​Revisions From 10.06.01l:
06/28/2023The policy has been reviewed and reissued to communicate the Company’s continuing position on Speech Therapy.
09/21/2022The policy has been reviewed and reissued to communicate the Company’s continuing position on Speech Therapy.
​04/07/2021
​This policy has been reissued in accordance with the Company's annual review proc​ess.
​01/01/2020
​The version of this policy will become effective 01/01/2020.

The intent of this policy remains unchanged, however, the policy has been updated to clarify current benefits regarding Maintenance Therapy.

The following CPT code has been termed from this policy: 97127.
The following HCPCS code has been termed from this policy: G0515.
The following CPT codes have been added to this policy: 97129 and 97130.

Revisions From 10.06.01k:
09/26/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Speech Therapy.
01/01/2018This policy has been identified for the CPT / HCPCS / Modifier code update, effective 01/01/2018.

The following CPT, Modifier codes have been termed from this policy:
97532, Modifier SZ

The following CPT, HCPCS, Modifier codes have been added to this policy
97127, G0515, Modifiers 96, 97

Effective 10/05/2017 this policy has been updated to the new policy template format.
1/1/2026
1/2/2026
10.06.01
Medical Policy Bulletin
Commercial
No
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.