Medical Necessity

Audiology and speech-language pathology services and devices are medically necessary to prevent, identify, evaluate, and treat speech-language, swallowing, cognitive-communication, hearing, and balance disorders.

On this page:

Identifying the Need for Services (Screening and Assessment)
Determining Medical Necessity
Admission and Discharge Criteria
Clinical Coverage

Identifying the Need for Services (Screening and Assessment)

A screening is a brief pass/fail procedure to identify individuals who require further assessment or referral to other professional and/or medical services. An assessment is more comprehensive, and it addresses speech, language, cognitive-communication, and/or swallowing function (strengths and weaknesses) in children and adults, including identification of impairments, associated activity and participation limitations, and environmental barriers that impact function.

An assessment is often prompted by referral, by the individual's medical status, educational performance, or by failing a speech-language or swallowing screening that is sensitive to cultural and linguistic diversity.

Assessments typically result in the following:

Diagnosis of speech, language, cognitive, communication, and/or swallowing disorders
Clinical description of the characteristics of speech, language, cognitive, communication, and/or swallowing impairments
Prognosis for change (in the individual or relevant contexts)
Recommendations for intervention and support
Identification of the effectiveness of intervention and supports
Referral for other assessments or services

Determining Medical Necessity

Determining medical necessity involves considering whether a service is essential and appropriate to the diagnosis and treatment of an illness, injury, or disease. Disease is defined as “an impairment of the normal state” (U.S. National Library of Medicine). Loss of hearing or balance, impaired speech and language, and swallowing difficulties all reflect an impairment of the “normal state,” and services to prevent or treat such impairment must be regarded as medically necessary.

Medicare defines medically necessary services as “health-care services or supplies needed to diagnose, or treat an illness, injury, condition, disease, or its symptoms, and that meet accepted standards of medicine.”
The Summary of Benefits and Coverage [PDF] and Uniform Glossary of Medical Terms [PDF] required by the Affordable Care Act (ACA) define medically necessary services [PDF] as follows: “Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms, including habilitation, and that meet accepted standards of medicine.”

Admission and Discharge Criteria

Admission to audiology or speech-language pathology services is based on referral or self-referral. Criteria for delivering medically necessary services include one or more of the following:

An evaluation by a licensed audiologist to verify the presence of a hearing disorder
An evaluation by a licensed SLP to verify the presence of a cognitive, communication, and/or swallowing disorder
The individual's cognitive, communication, and/or swallowing skills negatively affect performance, health, and/or safety

One or more of the following criteria provide a basis for discharge from audiology or speech-language pathology services:

Treatment no longer results in measurable benefit
The speech, language, communication, and/or feeding and swallowing disorder is now defined within “normal” limits or is now consistent with the individual's premorbid status
The individual has met treatment goals and objectives
The individual's speech, language, cognitive, communication, and/or feeding and swallowing skills no longer adversely affect the individual's performance, health, and/or safety
The individual who uses an AAC system has achieved optimal communication across environments and communication partners
The individual meets established nutrition and hydration needs by oral or alternative means (e.g., percutaneous endoscopic gastrostomy), and the individual demonstrates adequate swallowing function to manage oral and pharyngeal saliva accumulations
The individual has received maximum benefit from auditory rehabilitation
The individual has received an audiologic diagnostic evaluation, counseling on the results, and recommendations and referrals for continued care as appropriate

Other reasons for discharge include the following:

The individual is unwilling to participate in treatment, treatment attendance has been inconsistent or poor, and the clinician has tried unsuccessfully to address these factors
The individual, family, and/or guardian requests to be discharged or requests continuation of services with another provider
Transfer or discharge of the individual to another location, precluding ongoing service from the current provider

Although payers stipulate the parameters of services covered by their plan, ASHA's Code of Ethics and other guidance documents [PDF] support the independent clinical judgment of qualified audiologists and SLPs in delivering services and making recommendations. Clinical providers should not deliver or charge for unnecessary services, and they should not continue treatment after the patient has achieved maximum benefit.

Administrators should not mandate services based on quotas, productivity requirements, reimbursement levels, and other factors that do not relate to the individual needs of a patient/client. Similarly, administrators should not require clinicians to use codes, diagnoses, or treatment approaches when not indicated clinically.

Clinical Documentation

Essential elements of documentation include the following:

Pertinent background information, results, and interpretation of assessments and observations, prognosis, and recommendations for further assessment, follow-up, or referral, as appropriate
A description and results of procedures/assessments that the clinician has administered
Type and severity of the individual's disorder and associated conditions
Recommended frequency, estimated duration, and type of service (e.g., individual, group, co-treatment, and maintenance program)
Functional treatment goals and reports with updates at regular intervals
Upon discharge from services, progress on goals, discharge status, and further recommendations

Clinical Coverage

The National Association of Insurance Commissioners' (NAIC) Glossary of Health Insurance and Medical Terms [PDF] defines the term rehabilitative services as follows:

Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Habilitative Services

The NAIC's Glossary of Health Insurance and Medical Terms [PDF] defines the term habilitative services as follows:

Cover health care services and devices 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.

Habilitative services and devices meet the needs of a wide variety of children and adults with congenital deficits, autism spectrum disorder, cerebral palsy, disabilities, and other chronic and progressive conditions to acquire skills and functions never developed and to maintain their health and function.