Excellus BlueCross BlueShield (New York) pediatric speech and OT coverage: codes, limits and referrals
The short answerSLP and OT. Excellus covers habilitative and restorative speech, PT and OT for children with at least a moderate to severe delay, a standard score of 77 or below on most tests (1.5 SD). Sensory integration therapy and 97533 are not medically necessary, and pragmatic language disorders are excluded. School IEP services are not covered.
By Javier Alvarez · Updated · 1 min read
1 row: Excellus BlueCross BlueShield · New York. Public policy, not the member's benefits.
Excellus BlueCross BlueShield (New York)
Medical Policy 8.01.24 Therapies (Speech, Physical and Occupational) · New York
| 92507 | Listed (on the policy code list; criteria apply) [1] |
|---|---|
| 97530 | Listed (on the policy code list; criteria apply) [1] |
| 97533 | Not listed (sensory integrative techniques marked not medically necessary) [1] |
| 97535 | Listed (on the policy code list; criteria apply) [1] |
| Where it applies | Restorative or habilitative PT, OT or speech therapy is appropriate for children with at least a moderate to severe delay or disability from disease, trauma, congenital anomaly or developmental delay, found by standardized assessments. Moderate to severe is generally 1.5 standard deviations below the mean, a standard score of 77 or below. [1] |
| State law | The policy summarizes New York law as requiring autism spectrum disorder coverage that includes services by a licensed or certified speech therapist or occupational therapist, including habilitative or non-restorative care. This is the payer's description of the law, not the statute. [1] |
| Other codes | 97533 (sensory integrative techniques) and 97537 are marked not medically necessary on the code list. [1] |
| Visit limits | Continuing therapy needs maintenance level not yet reached, significant improvement on objective measures, and documentation of recent improvement, an updated plan and active participation. Some contracts cap short-term therapy visits per condition, and these visit limits do not apply when the therapy treats a mental disorder, including autism spectrum disorder. [1] |
| Referral | Coverage is not available for services given by school districts under a child's IEP. If outpatient therapy is requested on top of IEP or early intervention services, documentation must explain why more is needed beyond what the child gets at school. [1] |
| Also | Sensory integration therapy and hippotherapy are not medically necessary. Speech therapy is not medically necessary for pragmatic language disorders or oral myofunctional disorders. [1] |
What Excellus BlueCross BlueShield (New York)'s documents say
The table above has every field we found for Excellus BlueCross BlueShield (New York), with numbered sources. In short:
- Visit limits. Continuing therapy needs maintenance level not yet reached, significant improvement on objective measures, and documentation of recent improvement, an updated plan and active participation. Some contracts cap short-term therapy visits per condition, and these visit limits do not apply when the therapy treats a mental disorder, including autism spectrum disorder.
- Where it applies. Restorative or habilitative PT, OT or speech therapy is appropriate for children with at least a moderate to severe delay or disability from disease, trauma, congenital anomaly or developmental delay, found by standardized assessments. Moderate to severe is generally 1.5 standard deviations below the mean, a standard score of 77 or below.
- Codes. 92507, 97530 and 97535 are listed. 97533 is not listed.
Other pediatric speech and OT rows for New York
New York Medicaid (fee schedule).
Check Excellus BlueCross BlueShield (New York)'s claim against the row
Before the claim goes out, compare it with the row above: the evaluation and treatment codes are ones the policy lists, the plan of care and any prior authorization cover the date, and the visit count fits the limit. The pediatric speech and OT table compares Excellus BlueCross BlueShield with every other payer we checked.