Insurance Coverage: Obtaining Reimbursement for Stuttering Treatment
Approximately three million children and adults in the U.S. stutter. This guide provides suggestions and resources for obtaining payment for the treatment of stuttering.
1. Will my health plan cover stuttering treatment?
Before contacting your health plan, review your policy for coverage looking for such terms as “speech therapy,” “speech-language pathology,” “physical therapy and other rehabilitation services,” or “other medically necessary services or therapies.” A phone call to the health plan can confirm your interpretation of coverage. Document the name of the person with whom you speak as well as dates and times.
Provide the health plan with information about the neurological basis of stuttering; the available evidence states that stuttering is a “disorder associated with left inferior frontal structural anomalies” (Brain, 2009) and that ” adults with persistent stuttering … (have) anatomical irregularities in the areas of the brain that control language and speech” (Neurology, July 24, 2001). Children who stutter demonstrate atypical brain anatomy as well (Neuroimage, February, 2008).
When speaking with the health plan representative, it may be helpful to provide the appropriate diagnostic code for the type of stuttering you are seeking treatment coverage for. There are some recent changes in the relevant diagnostic codes. While the default code has typically been 307.0 for all forms of stuttering, new codes took effect in October 2010. These include a new “default” code of 315.35 for “Childhood onset fluency disorder” to include most cases of stuttering and cluttering. Adult onset stuttering, which is relatively rare, is covered by the codes 438.14 for stuttering following stroke, and 784.52 for fluency disorder secondary to other medical conditions. The prior default code (307.0) is to be used only for stuttering not described by these other codes. The treatment codes for stuttering include 92521 for speech evaluation, 92507 for individual speech treatment, and 92508 for group speech treatment.
Beginning on Jan. 1, 2014, the new CPT code 92521 is now used for Evaluation of speech fluency (e.g., stuttering, cluttering).
Be sure to get the name of the health plan representative with whom you talked and ask for confirmation of coverage in writing. Specifics of coverage (e.g., any limit on the number of sessions, co-payments, deductible amounts, etc.) should also be provided in writing. The health plan should provide this written notification within 30 to 60 days.
If treatment for stuttering is not covered by your policy, ask the health plan to explain the reasons for the denial in writing. This information can be helpful in appealing the original determination. Keep copies of all correspondence and detailed records of all verbal communication.
Sometimes health plans decline to cover conditions in the 315 “series” of codes, because they consider them “developmental”. If you receive such a response, it is important to emphasize that the 315.35 code specifically includes the wording “childhood onset” to make it clear that “stuttering evolves before puberty, usually between two and five years of age, without apparent brain damage or other known cause” (PloS Biology, February, 2004). It impairs previously normal fluency.
2. Does the health plan require a physician referral before payment for the treatment of stuttering?
Some insurers do require this pre-approval. Your policy booklet or your insurance representative should be able to tell you if your policy requires a referral from your primary physician prior to beginning treatment for stuttering. Pre-approval may be a form that your primary physician completes and submits to the health plan. Pre-approval may also require a letter of referral, which is submitted along with your insurance form to the health plan.
If a letter is required for pre-approval of treatment for stuttering, it should contain the following information:
__________________ is a patient of mine who stutters. This interferes with his/her oral communication. In order to treat this disorder, it is medically necessary that my patient receive specialized, comprehensive speech treatment from_________________________.
Typically, the health plan also requires a form from the speech-language pathologist, which includes the diagnostic and treatment codes for stuttering, projected treatment dates or number of treatment sessions anticipated, as well as associated fees. The health plan is required to notify you within 30 to 60 days as to the status of approval.
3. How do I submit a claim?
Speech treatment for stuttering is usually conducted in one of two ways: weekly sessions or intensive, short-term treatment programs.
A. Weekly Sessions
If speech treatment is provided once or twice a week, claims can be submitted in a number of ways: at the completion of each session, after a block of sessions, or filed with a projected number of sessions. If more sessions are needed than originally anticipated, a progress report is submitted to the health plan with a request for coverage for additional sessions. The speech-language pathologist can assist you in determining the best way to submit your claim, or may submit the claim for you.
B. Intensive Short-Term Treatment
If treatment is provided through an intensive short-term treatment program, the claim must be submitted at the completion of the program. Intensive shortterm treatment programs are typically conducted over a 2-4 week period.
Once the treatment program is completed, the speech-language pathologist will supply the appropriate diagnostic and treatment codes and either you or the clinician will submit this information, along with your insurance form, to the health plan.
Regardless of the type of treatment program recommended-weekly or intensive, short-term-you should call the health plan a week after mailing the claim to make certain it has been received.
4. What can I do if my claim is denied?
If your claim is denied, request the reasons for denial in writing. You have the right to appeal the denial. Remember, persistence often pays off.
First, write a letter stating your intention to appeal the denial. The health plan may request additional information about the treatment and/or they may ask for an objective measurement of progress. They may cite as a reason for denial that treatment is “educational in nature” or that treatment is not “medically necessary.” Your appeal must address the specific reasons for denial.
An appeal letter typically includes a description of the disorder and its medical nature. A copy of the physician’s referral letter (if pre-approval was needed) should be included. It may be helpful to quote those sections of the policy booklet that describe the coverage for speech-language pathology treatment, if it helps your case. Then you will need to describe how the treatment meets the policy criteria.
In any correspondence with the health plan:
• Use terms that are medically oriented (e.g., evaluation, diagnosis, condition) rather than behavioral or learning theory terminology (e.g., test, examination, teach).
• Do not include the time of onset of stuttering, unless specifically requested.
• Include estimated length of treatment if known.
• Indicate that treatment is provided by an ASHA-certified, and licensed (where Applicable) speech-language pathologist and include the clinician’s ASHA certification number and state license number.
• Demonstrate significant practical improvement using objective, measurable terms.
• Document improvement by indicating how the patient has applied progress in treatment to real life situations (may be referred to as functional outcomes).
Your speech-language pathologist can help you with this appeal. Sample appeal letters are also available through the American Speech-Hearing-Language Association (ASHA).
Once the health plan receives the information, they must respond within a time period of 30 to 60 days depending upon the state. Follow up and persistence can lead to success!
5. What action can I take if my appeal is denied?
If you feel that your appeal has been unfairly denied or that your case was handled unprofessionally or inappropriately, there is action that can be taken.
• Contact your state insurance commissioner to determine if there are any other instances in which claims have been unfairly denied and/or file a complaint. Contact information for your insurance commissioner can be found by contacting the Publications Department of the National Association of Insurance Commissioners at 816-783-8300, by fax at 816-460-7593, or visit http://www.naic.org.
• Consider filing a claim in small claims court or state court if all other efforts fail.
6. Are there any other ways to pay for treatment?
There are other ways to pay for treatment if you are having difficulty financing yourself. Here are some alternatives:
• Most states have an agency that helps handicapped or disabled individuals. The names vary from state to state but are usually called Departments of Vocational Rehabilitation. You can find your state’s department by calling information at your state capitol. Contact the agency to see if you qualify. Most states require a minimum age of 18 for vocational rehabilitation services.
• You can request financial help from your local civic organizations like the Elks Club, Lions, Rotary, Sertoma, etc.