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.

• The standard diagnostic code is ICD-10-CM F80.81 for “Childhood onset fluency disorder” to include most cases of stuttering and cluttering.
• The treatment codes (“CPT”) for stuttering include 92521 for speech evaluation, 92507 for individual speech treatment, and 92508 for group speech treatment.

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 coverage for stuttering therapy because they consider them “developmental.” If you receive such a response, it is important to emphasize that the diagnostic 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.

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.

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.

Once the treatment program is completed, the speech-language pathologist will supply the appropriate diagnostic and treatment codes and you will submit this information, along with your insurance form, to the health plan.

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!

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 www.naic.org.
• Contact the Stuttering Foundation of America at 800-992-9392, info@StutteringHelp.org or visit www.StutteringHelp.org.