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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
 
2. The services require the skills or direct supervision of a therapist,  
 
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
 
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 220.2. 
 
The rules say that Speech/hearing therapy 
 
The treatment/intervention, (e.g., prevention, restoration, amelioration, and compensation) and follow-up 
services for disorders of speech, articulation, fluency and voice, language skills and the cognitive aspect of 
communication. 
 
    1. Providing consultation, counseling, and making referrals when appropriate. 
    2. Providing training and support to family members/caregivers and other communication partners of 
individuals with speech, voice, language, communication, fluency and hearing disabilities. 
    3. Developing and establishing effective augmentative and alternative communication techniques and 
strategies, including selecting, prescribing and dispensing of aids and devices as identified by State Practice 
Acts; and training individuals, their family members/caregivers, and other communication partners in their use. 
    4. Establishing effective use of appropriate prosthetic/adaptive devices for speaking. 
    5. Providing rehabilitation services for the auditory system, and related counseling services to individuals 
with hearing loss and to their family members/caregivers. For further details, please see CMS IOM Publication 
100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220, referenced in the CMS National Coverage 
Policy section of this policy. 
    6. Providing interventions for individuals with central auditory processing disorders; and/or 
    7. Modification or training in use of a voice prosthetic. Modifications in a voice prosthetic to supplement 
oral speech would be appropriate and should be carried out by a speech-language pathologist. The patient is 
seen for sizing, fitting, placement or replacement and training of the voice prosthetic. 
 
Speech/hearing therapy (group) 
 
For the purpose of performing group therapy, a group is defined as two or more individuals receiving active 
therapy, Please see CMS IOM 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230 for more 
information on group SLP services. 
 
Therapeutic services (patient adaptation and training) for the use of speech-generating devices 
 
 
Patient adaptation and training for the use of speech-generating devices includes the development of 
operational competence in using a speech-generating device or aids, to include customizing the features of the 
device to meet the specific communication needs of each patient and providing opportunities for developing 
skill in all aspects of device use. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Speech - Language 
Pathology (SLP) Services: Communication Disorders (L35070). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.