Model Health Care Benefits

Ideal Health Plan Coverage for Audiology and Speech-Language Pathology Services

Hearing Benefits | Speech & Language Benefits | Resources

These model benefit plans for audiology and speech-language pathology services and devices were developed by ASHA to provide a document that offers guidance as to appropriate coverage levels. The model benefit plans include:

Audiology and speech-language pathology services that should be included;
The circumstances under which the services should be covered;
Recommendations regarding appropriate coverage levels; and
Recommendations for device allowances (e.g., hearing aids, augmentative and alternative communication devices).

For questions, please contact reimbursement@asha.org.

All Current Procedural Terminology (CPT®) codes and descriptors are copyright American Medical Association.

Model Hearing Benefits Plan

Services and Devices ^[1]	Coverage Level & Device Allowances	CPT and HCPCS Codes
Evaluation & Management: Medical Team Conferences, Telephone Assessment and Management, and Online Assessment and Management	Covered in full for the pediatric and adult populations for all medical diagnoses that have an ICD-10-CM code.	Evaluation & Management codes include, but are not limited to: 98966, 98967, 98968, 98970, 98971, 98972, 99366, 99368
Assessment: Audiological, Tinnitus, Vestibular and Balance, Central Auditory, Cochlear Implant, Hearing Assistive Technology Systems (HATS), Auditory Rehabilitation, Hearing Aid Assessment and Fitting	Covered in full for the pediatric and adult populations for all medical diagnoses that have an ICD-10-CM code.	Assessment codes include, but are not limited to: 92537, 92538, 92540 through 92550, 92552 through 92568, 92570 through 92596, 92601 through 92604, 92620, 92621, 92625, 92626, 92627, 92640, 92700, 95920, 95925, 95930, 95934, 95936, 95937, V5008, V5010, V5011, V5014, V5020
Treatment: Audiologic (Aural) Rehabilitation/Habilitation, Vestibular and Balance, Auditory Processing, Cerumen Management, Canalith Repositioning	Covered in full for the pediatric and adult populations for all medical diagnoses that have an ICD-10-CM code as long as measurable and positive functional change is noted in a reasonable time period. ^[2]	Treatment codes include, but are not limited to: 92507, 92630, 92633, 95992, 69209, 69210
Devices: Hearing Aid Devices, HATS, Cochlear Implants and Accessories	$3,000 hearing aid or HATS allowance per ear every 3 years Replacement earmolds covered in full up to four times per year for children 7 years of age or under $5,000 cochlear implant speech processor allowance every 5 years A HATS for use specifically with a cochlear implant covered in full once every 5 years	Device codes include, but are not limited to: V5030 through V5265, V5267 through V5269, V5273, V5275, L8619, L7510

[1] Services and devices should be provided by an ASHA Certified and, where applicable, state licensed audiologist.

[2] If a limit on the number of sessions is established, the audiologist should be given the flexibility to determine the frequency and length of the sessions as well as the duration of treatment.

Model Speech and Language Benefit Plan

Services and Devices ^[1]	Coverage Level & Device Allowances	CPT and HCPCS Codes
Evaluation & Management: Medical Team Conferences	Covered in full for the pediatric and adult populations for all medical diagnoses that have an ICD-10-CM code.	Evaluation & Management codes include, but are not limited to: 98966, 98967, 98968, 98970, 98971, 98972, 99366, 99368
Assessment: Speech, Language, Voice, Stuttering, Communication, Cognitive, Auditory Processing, Auditory (Aural) Rehabilitation, Swallowing Function, Augmentative and Alternative Communication (AAC), Voice Prosthetic	Covered in full for the pediatric and adult populations for all medical diagnoses that have an ICD-10-CM code.	Assessment codes include, but are not limited to: 92511, 92520 through 92524, 92597, 92605, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 92626, 92627, 96105, 96110, 96112, 96113, 96125
Treatment: Speech, Language, Voice, Stuttering, Communication, Auditory Processing, Auditory (Aural) Rehabilitation/Habilitation, Cognitive Rehabilitation, Swallowing Function, AAC, Voice Prosthetic	Covered in full for the pediatric and adult populations for all medical diagnoses that have an ICD-10-CM code as long as measurable and positive functional change is noted in a reasonable time period. ^[2]	Treatment codes include, but are not limited to: 92507, 92508, 92526, 92606, 92609, 92618, 92630, 92633, 97110, 97112, 97129, 97130, 97150, 97530, 97533 ^[3]
Devices: AAC and Prosthetic Devices & Accessories	Covered in full if recommended by an ASHA-certified, and/or licensed speech-language pathologist.	Device codes include, but are not limited to: E1902, E2500 through E2512, E2599, L8500 through L8515, V5336

[1] Services and devices should be provided by an ASHA Certified and, where applicable, state licensed speech-language pathologist.

[2] If a limit on the number of sessions is established, the speech-language pathologist should be given the flexibility to determine the frequency and length of the sessions as well as the duration of treatment.

[3] The Centers for Medicare & Medicaid Services advises that use of physical medicine and rehabilitation codes (9700 series) are not appropriate for speech-language pathology or dysphagia services, except for 97129/97130 and 97533. Some Medicare contractors, Medicaid programs, and private payers may allow exceptions. Speech-language pathologists should discuss the appropriate use of the 97000 series of codes with the payer.