Rehabilitative Services Policy
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Defines medical necessity, coverage criteria, limitations, prior authorization and billing guidance for outpatient physical therapy, occupational therapy, and speech therapy for Aloha Care members.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Physical and Occupational Therapy - Medical Necessity
Covered when ALL of the following are met
Must be documented in the medical record.
Provider licensure and supervision must be documented.
Order must specify the impairments being addressed.
PT/OT Coverage Criteria
- Significant improvement definition: Significant improvement means a measurable and meaningful increase in the patient's physical and functional abilities that can be attained with short-term therapy, usually within a three-month period.
- Measures of progress - Physical therapy: Active range of motion; strength; motor exam; functional abilities.
- Measures of progress - Occupational therapy: Useful and purposeful activities (neuromusculoskeletal); guidance in selection and use of orthoses; functional abilities (skills and deficits).
Home program must be in the record.
Frequency/duration must be justified in the record.
Speech Therapy - Medical Necessity
Speech therapy is covered when:
Provider qualifications and clinical necessity must be documented.
Providers must submit PA with required documentation listed in administrative guidelines (see documentation requirements).
Coverage limitations for outpatient physical therapy (PT) and occupational therapy (OT) include situations where services overlap in purpose and intervention. PT or OT is not covered when any other therapy is provided concurrently with the same interventions and treatment for the same purpose. Additionally, PT/OT are not covered for activities that are recreational, educational, or primarily for general fitness such as leisure activities, general exercise programs, programs to provide diversion or motivation, ongoing treatment solely to improve endurance/distance, or routine educational/training/conditioning.
Other specific limitations include long-term therapy, services for developmental delay (significant lag compared with norms), and remote or tele-health physical therapy. Certain modalities are considered components of the comprehensive PT/OT plan and are not separately reimbursed (for example: functional activities/activities of daily living, infrared/ultraviolet, massage/myofascial release, microwave/infrared, orthotics/prosthetic training, and whirlpool/Hubbard tank).
The policy also lists several interventions that are considered experimental, investigational, or unproven and therefore not covered, including electrical stimulation (E-stim/NMES) for swallowing/feeding disorders, adhesion removal for bowel obstruction, Applied Functional Science, blood flow restriction therapy, Dynamic Movement Intervention, Kinesio/McConnell Taping, and 'hands free' ultrasound/low-frequency sound (infrasound).
PT and OT are considered not medically necessary when there is no demonstrable clinical benefit or when expected functional gains are reasonably likely to occur without formal therapy. Specifically, services are not medically necessary if the member's condition does not show improvement or if the member’s function could reasonably be expected to improve as they gradually resume normal activities.
This policy therefore does not support continued treatment solely to maintain function without measurable improvement or ongoing services that extend beyond a reasonable and predictable timeframe without documented progress toward stated goals.
Procedure Codes and Coding Guidance
| 64550 | Application of surface (transcutaneous) neurostimulator. |
| 90901 | Biofeedback training by any modality. |
| 90911 | Biofeedback training, perineal muscles, anorectal or urethral. |
| 92522 | Evaluation of speech sound production. |
| 92523 | Evaluation of speech sound production with evaluation of language comprehension and expression. |
| 92526 | Treatment of swallowing dysfunction and/or oral feeding. |
| 92597 | Evaluation for use and/or fitting of voice prosthetic device. |
| 92605 | Evaluation for prescription of non-speech-generating augmentative and alternative communication device. |
| 92606 | Therapeutic services for use of non-speech-generating device, including programming and modification. |
| 92607 | Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face; first hour. |
Prior Authorization, Documentation, and Denial Triggers
Obtain prior authorization for speech therapy and treatment-plan changes
Prior authorization (PA) is required for all speech therapy evaluations and treatments, and for any changes in the treatment plan. Exceptions: PA is not required for the first two PT/OT evaluations within a six-month period and PA is not required for one PT/OT treatment on the same day as the initial evaluation or re-evaluation.
- PA required for evaluation and treatment for speech therapy.
- PA required for changes in treatment plan.
- No PA required for the first 2 PT/OT evaluations in a six-month period.
- No PA required for one PT/OT treatment on the same day as initial evaluation or re-evaluation.
Reference codes, licensure, and home program when submitting requests
Ensure requests reference applicable procedure codes from Table 1 and confirm services are ordered and provided by appropriately licensed practitioners; maintain a home exercise/education program initiated at the first visit with documentation of participation/compliance.
- Use the procedure codes listed in Table 1 when preparing administrative requests or claims.
- Orders must be from a physician or other licensed practitioner qualified to prescribe PT/OT and services delivered by licensed PT/OT/ST within scope and supervision.
- Document a home exercise/education program started at the first visit with evidence of participation/compliance.
Submit complete PA documentation including individualized written treatment plan
Include an individualized written treatment plan with PA submissions that documents diagnosis, date of onset/exacerbation, evaluation, measurable SMART goals, measurable objectives, estimated time to reach goals, and the frequency/duration with intended procedure codes and specific procedures/modalities (including home program).
- Diagnosis, symptoms and evaluation findings documenting medical necessity
- Date of onset or exacerbation of the disorder/diagnosis
- Long-term and short-term goals that are specific, measurable, attainable, relevant, and time bound (SMART)
- Therapy evaluation and measurable objectives to facilitate significant functional improvement
- Estimated timeframe for goal attainment
- Frequency and duration of treatment with intended procedure codes (e.g., 15-minute modality codes)
- Specific procedures/modalities to be used, including those for a home maintenance program
Avoid services that trigger denials (concurrent same-purpose therapy or experimental interventions)
Therapies will be denied when provided concurrently with another therapy using the same interventions for the same purpose, and when interventions are listed as experimental, investigational, or unproven (e.g., E-stim/NMES for swallowing, blood flow restriction therapy, Kinesio Taping, hands-free ultrasound/infrasound, adhesion removal for bowel obstruction, Applied Functional Science, Dynamic Movement Intervention).
- Concurrent provision of another therapy using the same interventions and for the same purpose.
- Interventions explicitly listed as experimental/investigational/unproven, including electrical stimulation (E-stim/NMES) for swallowing/feeding disorders, adhesion removal for bowel obstruction, Applied Functional Science, blood flow restriction therapy, Dynamic Movement Intervention, Kinesio Taping/McConnell Taping, and 'hands free' ultrasound/low-frequency sound (infrasound).
Background and Rationale
Physical therapy (PT), occupational therapy (OT), and speech therapy (ST) are rehabilitative services provided to restore, maintain, or improve functional abilities following disease, injury, surgery, congenital anomalies, or prior interventions. These services must be medically necessary and directed toward measurable, diagnosis-related functional goals with a reasonable expectation of improvement within a predictable timeframe.
PT and OT focus on improving movement, strength, mobility, and the ability to perform activities of daily living; ST addresses disorders that impair speech, voice, language, or swallowing. The policy defines significant improvement as a measurable and meaningful increase in the patient’s physical or functional abilities that can ordinarily be achieved within a short-term therapy course (usually within three months).
Key Definitions
Policy Revision History
Policy original effective date established.
Policy review/revision recorded (Review/Revision Dates).
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