Most insurance plans have a "medical necessity" or "injury and illness" clause. Oftentimes a patient tells me their insurance plan covers speech. However, once we verify their benefits with the insurance company, we often come across this confusing clause.

What does a "medical necessity" clause mean for my coverage?

Put simply, it often means that if an impairment is not caused by a medical diagnosis, injury, or illness, that your plan does not cover intervention for that impairment. Many developmental diagnoses, such as articulation, receptive and expressive language, wouldn't be covered...unless they were due to a medical  Diagnosis. Examples of these medical diagnosis might be: cerebral palsy, stroke, brain injury, etc. 

Is there any way to get around this, or to appeal?

Yes. At SAGE, we often take the time to write letters of medical necessity on behalf of our clients, and accompany these letters with a physician's prescription for speech therapy services. SAGE Speech & Learning will ask you for a detailed medical history for your child to help build a case for speech coverage. 

SAGE Can't Over Emphasize the Importance of Proper Codes!

What are the proper diagnosis and procedure codes for speech?

It's important to use correct codes for insurance to process claims accurately and quickly. SAGE works tirelessly to assist providers and families to effectively file for insurance coverage, when available.

The Most Common Codes for Diagnosis:

Articulation - f80.0  

Expressive Language- f80.1  

Mixed Receptive Expressive Language- f80.2 

The Most Common Procedural Codes:

Procedure for Speech Language Therapy- 92507

Feeding and Swallowing Therapy- 9252

Finally, what insurance plans does SAGE accept? 

SAGE is in-network Blue Cross Blue Shield, and as mentioned, SAGE will provide a super bill free of charge for all private insurances. Additionally, SAGE accepts Medicaid and Katie Becket Waivers.

Call SAGE today to learn more!