Speech therapy is covered to improve, restore or maintain function, or to minimize or prevent deterioration of function.
All active duty service members (ADSMs), TRICARE Prime and TRICARE Prime Remote beneficiaries who have an assigned primary care manager (PCM) require an approval from Health Net Federal Services, LLC (HNFS) for speech therapy services. TRICARE Prime Remote beneficiaries (excluding ADSMs) without an assigned PCM and TRICARE Select beneficiaries do not require an approval from HNFS prior to services being rendered; however, a physician’s order is required for claims processing.
Coverage is based on the beneficiary's medical needs. The number of visits authorized indicates the actual number of visits, not the individual units per CPT® code. The following baselines will be used as a guide for the number of visits and duration of approval:
- Acute injuries (for example, shoulder sprain, muscle tear) = 12 visits with a duration of 120 days
- Post-operative care (for example, removal of vocal cord nodule) = 24 visits with a duration of 150 days
- Long term conditions (for example, neurological conditions such as stroke, traumatic brain or spinal cord injury, pediatric neurodevelopmental conditions, swallow testing or feeding therapy) = 72 visits with a duration of 180 days
Individualized Education Program (IEP) Requirements
Speech therapy to treat a speech deficiency due to a cognitive or developmental disorder for beneficiaries age three to 21 requires a physician letter of attestation whenever there is evidence presented to TRICARE that there is an individualized education program in place for special education services. TRICARE may cover additional speech therapy when a physician attests in writing that the intensity and/or timeliness of any speech therapy services being offered by the educational agency does not meet the medical needs of the beneficiary.
The following speech therapy services are not a covered benefit (this list is not all inclusive):
- myofunctional or tongue thrust therapy
- maintenance therapy that does not require a skilled level of assistance
- services provided to address disorders or conditions resulting from occupational deficits
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