C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-109, subsec. 144-101-II-109.04
Services for members of all ages must be medically necessary and ordered by a practitioner of the healing arts as allowed by the respective licensing authority and his or her scope of practice. The Department or its authorized agent has the right to perform medical eligibility determination and/or utilization review to determine if services are medically necessary.
Adult members (age twenty-one (21) and over) must have an initial evaluation by a physician or PCP documenting that the member has experienced a significant decline in his/her ability to communicate orally/visually, safely swallow or masticate, and that the member has rehabilitation potential; or that the member may suffer a significant deterioration in ability to communicate orally/visually, safely swallow or masticate that would result in an extended length in stay or placement in an institutional or hospital setting. This requirement will not apply to members with Medicare coverage or other third party health insurance until the coverage for speech therapy services by the other payer has been exhausted.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-109, subsec. 144-101-II-109.04