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December 2016 Texas Medicaid Provider Procedures Manual

Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook : 5 Children’s Therapy Services Clients birth through 20 years of age : 5.3 Developmental Delay Criteria

5.3
To establish a developmental delay, all of the following criteria must be met:
Retesting with norm-referenced standardized test tools for reevaluations must occur every 180 days. Tests must be age appropriate for the child being tested and providers must use the same testing instrument as used in the initial evaluation. If reuse of the initial testing instrument is not appropriate, i.e. due to change in client status or restricted age range of the testing tool, provider should explain the reason for the change.
Eligibility for therapy will be based upon a score that falls 1.5 standard deviations (SD) or more below the mean in at least one subtest area of composite score on a norm-referenced, standardized test. Raw scores must be reported along with score reflecting SD from mean.
When the client’s test score is less than 1.5 SD below the mean, a criterion-referenced test along with informed evidenced-based clinical opinion must be included to support the medical necessity of services and may be sent to physician review to determine medical necessity.
If a child cannot complete norm-referenced standardized assessments, then a functional description of the child’s abilities and deficits must be included. Measurable functional short and long term goals will be considered along with test results. Documentation of the reason a standardized test could not be used must be included in the evaluation.
Specific developmental delay criteria requirements for speech diagnoses are as follows:
Language—at least one norm-referenced, standardized test with good reliability and validity, a score that falls 1.5 SD or more below the mean, and clinical documentation of an informal assessment that supports the delay
Articulation—at least one norm-referenced, standardized test with good reliability and validity, a score that falls 1.5 SD or more below the mean, and clinical documentation of an informal assessment that supports the delay
Apraxia—at least one norm-referenced, standardized test with good reliability and validity, a score that falls 1.5 SD or more below the mean, and clinical documentation of an informal assessment that supports the delay
Fluency—at least one norm-referenced, standardized test with good reliability, a score that falls 1.5 SD or more below the mean, and clinical documentation of an informal assessment that supports the delay
If the client’s test score is less than 1.5 SD below the mean, additional documentation supporting the client’s medical need for therapy will be considered and the request will be sent to physician review to determine medical necessity.
Additional speech therapy visits or sessions may be considered for moderate speech language, articulation, voice and dysphagia developmental delays when documentation submitted supports medical necessity as delineated in the frequency criteria in this handbook.

Texas Medicaid & Healthcare Partnership
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