Health plans, both public and private, cover services that are considered medically necessary. However, the definition of medical necessity can vary from payer to payer. Although there may not be one standard or generally accepted definition for medical necessity, the following information can help support arguments that speech, language, and hearing services meet medical necessity criteria.
Paul Keckley, a health economist and policy expert with extensive experience in health services research in the private sector and academic medicine, writes in a blog post "Medical necessity means something slightly different in every part of the health care industry. Varied definitions and interpretations are used by providers, physicians, courts, pharmacy benefits managers, government insurers, private insurers, and consumers."
Medicare defines medically necessary as "health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms, and that meet accepted standards of medicine."
Under the Affordable Care Act (ACA), health insurers and group health plans must provide clear, consistent, and comparable information about their health plan benefits and coverage. This information is published in documents called the Summary of Benefits & Coverage and Uniform Glossary of Medical Terms. The Uniform Glossary of Medical Terms [PDF] provides the following definition for medically necessary:
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.
This definition is particularly relevant for speech, language, and hearing services because children’s needs are often habilitative—rather than rehabilitative—in nature.
State law and regulation may also offer a definition. For example, In April 2000, the State of Texas and Aetna U.S. Healthcare entered into a settlement agreement concerning alleged violations by Aetna of the Texas Deceptive Trade Practices Act. In the settlement agreement, Aetna agreed that medically necessary care was to be defined as "health services and supplies that under the applicable standard of care are appropriate: (a) to improve or preserve health, life, or function; or (b) to slow the deterioration of health, life, or function; or (c) for the early screening, prevention, evaluation, diagnosis or treatment of a disease, condition, illness or injury."
The definition for medical necessity offered in this settlement agreement between the State of Texas and Aetna supports the medical necessity of speech, language, and hearing treatment. Communicating through speech or through augmentative and alternative communication (AAC) devices, being able to swallow, and being able to hear are vital for "health, life, or function."
Another payer, UnitedHealthcare, defines medical necessity [PDF] in this way:
Based upon a foundation of evidence-based medicine, medical necessity is the process for determining benefit coverage and/or provider payment for services, tests or procedures that are medically appropriate and cost-effective for the individual member.
UnitedHealthcare brings into the definition of medical necessity the importance of evidence-based practice. ASHA’s searchable online Evidence Maps can help audiologists and speech-language pathologists provide evidence-based conclusions and recommendations on screening, assessment, treatment, and service delivery.
Audiology and speech-language pathology services are medically necessary to treat speech-language, swallowing, cognitive communication, hearing, and balance disorders. Many of these disorders—such as head injury, Parkinson’s disease, stroke, autism, and cerebral palsy—have a neurological basis. Determining medical necessity takes into consideration whether a service is essential and appropriate to the diagnosis and/or treatment of an illness, injury, or disease. The U.S. National Library of Medicine defines disease as “an impairment of the normal state.” Loss of hearing, impaired speech and language, and swallowing difficulties all reflect an impairment of the normal state, and services to treat such impairment must be regarded as meeting medical necessity.
Habilitation services, referenced in the ACA definition of medical necessity, treat illness, injury, condition, and diseases (or symptoms) and, thus, should be included in definitions of medical necessity.Developmental deficits requiring habilitation services meet medical necessity. A diagnosis of developmental deficit in a child indicates an abnormal state of function, and speech, language, and hearing services are as medically necessary for this patient as they are for an adult who has suffered a stroke and has lost speech and language function.
Relevant documentation for establishing medical necessity may include the following:
Denials for health plan coverage can be appealed. According to data collected by the U.S. Government Accountability Office (GAO), 40% of appeals result in reversals. Refer to the health plan’s definition of medical necessity, and provide evidence supporting why the requested care fits within that definition. Audiologists and speech-language pathologists must document how the services that they provide meet medical necessity.