CurrentAmbetter NevadaPolicy CP.MP.49

Physical, Occupational, and Speech Therapy Services — Coverage Criteria

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Guidelines for medical necessity, authorization, continuation, reevaluation, and discontinuation of outpatient or home speech, occupational, and physical therapy services for Ambetter Nevada members; applies to providers requesting authorization for evaluation and treatment.

Policy Summary

PayerAmbetter Nevada

PolicyPhysical, Occupational, and Speech Therapy Services

Policy CodePolicy CP.MP.49

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain initial authorization and submit a signed plan of care with diagnosis, measurable goals, and planned interventions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial, continued, reevaluation, discontinuationcoverage stages

Once every 6 monthsreevaluation frequency

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CurrentAmbetter NevadaPolicy CP.MP.49

Physical, Occupational, and Speech Therapy Services — Coverage Criteria

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Policy Summary

PayerAmbetter Nevada

PolicyPhysical, Occupational, and Speech Therapy Services

Policy CodePolicy CP.MP.49

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain initial authorization and submit a signed plan of care with diagnosis, measurable goals, and planned interventions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial, continued, reevaluation, discontinuationcoverage stages

Once every 6 monthsreevaluation frequency

Dominant languagespeech language req

Detailed POCPOC requirements

Coverage Criteria for Therapy Services

Initial Therapy

Covered when ALL of the following are met:

Initial Authorization: 1) Signs and symptoms of physical deterioration or impairment in one or more of the following areas: sensory/motor ability; functional status evidenced by inability to perform basic activities of daily living (ADLs) and/or mobility; cognitive/psychological ability; cardiopulmonary status; or speech/language/swallowing/cognitive-communication disorders that result in disability.

Initial Authorization: 2) Treatment is ordered by an examining physician or other qualified healthcare professional, and a formal evaluation is conducted by a licensed/registered speech, occupational, or physical therapist that includes: history of illness or disability; relevant review of systems; pertinent physical assessment; current and previous level of functioning; tests or measurements of physical function; assessment of potential for improvement; recommendations for treatment and patient/caregiver education. (If request is for speech therapy, the evaluation must be conducted in the member's dominant language.)

Initial Authorization: 3) Treatment requires the judgment, knowledge, and skills of a licensed/registered therapist or therapy assistant and cannot be reasonably learned and implemented by nonprofessional or lay caregivers. (Repetitive drills not requiring professional feedback are not covered.)

Initial Authorization: 4) Treatment meets accepted discipline-specific clinical practice standards and is targeted and effective for the diagnosed impairment or condition.

Initial Authorization: 5) Treatment does not duplicate services provided by other therapy types or services provided in multiple settings.

Initial Authorization: 6) Treatment conforms to a written plan of care (POC) signed by the therapist that includes: diagnosis with date of onset/exacerbation; measurable short- and long-term functional goals specific to the condition; planned treatment techniques/interventions with amount, frequency, and duration; member/caregiver education and a home exercise/program when applicable; brief history of prior treatment; description of current level of functioning and barriers; most recent standardized evaluation scores when appropriate (with age equivalency, percent delay, or SD score); meaningful clinical observations and brief prognosis; and member agreement to the POC. (Note: standardized scores ≥ 1.5 SD below the mean may qualify but are not sole criterion.)

Initial Authorization: 7) Treatment is expected to: produce clinically significant and measurable improvement within a reasonable and medically predictable time frame, or prevent significant functional regression as part of a medically necessary program.

Initial Authorization: 8) For in‑home services, the treatment can be safely and adequately performed in the home and the diagnosed impairment or condition makes transportation to an outpatient rehabilitation facility impractical or medically inappropriate.

Continuation Therapy

Covered when ALL of the following are met:

Continuation Therapy: A) Documented treatment progress in an updated POC/current progress summary signed by the therapist and submitted at the end of each authorization period or when additional visits are requested. Documentation must include: 1) updated standardized evaluation scores with age equivalency/percent delay/SD score if applicable; 2) objective measures of functional progress relative to each treatment goal with comparison to prior report; 3) summary of response and issues limiting progress; 4) documentation of member or caregiver participation; 5) documentation of participation/adherence with a home exercise program if applicable; 6) brief prognosis with clearly established discharge criteria; 7) explanation and clinical rationale for any POC changes; 8) prescribed treatment modalities with anticipated frequency and duration; 9) physician or other qualified healthcare professional signature on the POC or prescription; 10) if applicable, IFSP/IEP or attestation verifying no duplication of services for children with developmental delays.

Continuation Therapy: B) If treatment is to be performed in the home: 1) the treatment can be safely and adequately performed in the home environment; and 2) the diagnosed impairment or condition makes transportation to an outpatient rehab facility impractical or medically inappropriate.

Reevaluation

Formal reevaluation by a licensed/registered therapist is considered medically necessary up to once every six months when ALL of the following apply:

Reevaluation: There is documentation of either: 1) new clinical findings or a significant change in condition that was not anticipated in the POC; or 2) failure to respond to therapeutic interventions outlined in the POC.

Discontinuation / Not Medically Necessary

Services are no longer medically necessary when ANY of the following apply:

Discontinuation/Not Medically Necessary: 1) Treatment goals have been achieved as evidenced by one or more of: no longer demonstrates functional impairment or has achieved POC goals; returned to baseline function; will continue with a home exercise program; has adapted to impairment with assistive equipment/devices; is able to perform ADLs with minimal to no assistance.

Discontinuation/Not Medically Necessary: 2) A functional plateau in progress has been reached, or additional therapy will no longer be beneficial (including failure to benefit/progress despite POC interventions or attainment of maximum medical benefit).

Discontinuation/Not Medically Necessary: 3) Member is unable to participate in the POC due to medical, psychological, or social complications.

Discontinuation/Not Medically Necessary: 4) Non‑compliance with a home exercise program and/or lack of participation in scheduled therapy appointments.

Services that consist of repetitive drills not requiring a licensed or certified therapist's feedback are excluded from coverage. Additionally, therapy that duplicates services already being provided by another therapy type or in multiple settings is not considered medically necessary. All covered therapy must be unique, require therapist judgment, and align with accepted discipline-specific clinical standards.

A written plan of care (POC) signed by the treating therapist is required and must document diagnosis with date of onset, measurable short- and long-term functional goals, planned treatment techniques with amount, frequency, and duration, education/home exercise plan, prior treatment history, current level of functioning and barriers, standardized evaluation scores when appropriate, clinical observations and prognosis, and member agreement to participate. Standardized scores of ≥ 1.5 SD below the mean may support medical necessity but cannot be the sole criterion.

Treatment is no longer medically necessary when goals have been achieved (for example, the member no longer demonstrates functional impairment, has returned to baseline, can continue with a home exercise program, has adapted with assistive devices, or can perform ADLs with minimal or no assistance).

Services are also not medically necessary when a functional plateau is reached and further therapy will not be beneficial, when the member is unable to participate in the plan of care due to medical, psychological, or social complications, or when there is non‑compliance with the home exercise program and/or repeated failure to participate in scheduled therapy appointments.

Scoring Thresholds and Coding Notes

inv-07: Standardized score threshold — Scores ≥ 1.5 SD below the mean may qualify; score not sole criterion

Threshold valueStandardized scores ≥ 1.5 standard deviations (SD) below the mean may qualify as medically necessary (except where state requirements differ)

Use in determinationA score at or below this threshold may support medical necessity but may not be used as the sole criterion for initial or continuing treatment decisions

Required documentation contextInclude most recent standardized evaluation scores in the POC with age equivalency, percent of functional delay, or SD score when appropriate

Scope/applicabilityApplies to standardized evaluation scores reported in the written plan of care for therapy disciplines covered by this policy

Provider Requirements, Documentation, and Authorization

Prior Authorization

Initial authorization required — all listed criteria must be met

Initial authorization is required and considered medically necessary only when ALL listed criteria are met, including: presence of signs/symptoms of physical deterioration or impairment in specified domains; treatment ordered by an examining physician or qualified healthcare professional; a formal evaluation by a licensed/registered therapist that includes specified evaluation components (history, ROS, physical assessment, current/previous functioning, tests/measurements, potential for improvement, recommendations/education; speech evaluation in the member's dominant language); treatment requires therapist judgment/skills and cannot be reasonably provided by lay caregivers; treatment meets accepted discipline‑specific standards and is targeted/effective for the diagnosed impairment; treatment does not duplicate other services or settings; treatment conforms to a written plan of care signed by the therapist with required elements; treatment is expected to produce measurable improvement or prevent significant regression (or, if in‑home, can be safely performed at home and transportation is impractical/medically inappropriate).

Signs/symptoms in one or more areas (sensory/motor, ADLs/mobility, cognitive/psychological, cardiopulmonary, speech/language/swallowing).
Treatment ordered by an examining physician or qualified provider; formal therapist evaluation as specified.
Treatment requires licensed therapist judgment and is not reasonable for lay caregivers; repetitive drills without professional feedback are not covered.
POC must be written and signed by therapist and include diagnosis/onset, measurable short‑ and long‑term goals, planned techniques with amount/frequency/duration, education/HEP, prior treatment history, current level/barriers, standardized scores when appropriate, clinical observations/prognosis, and member agreement.

Definitions and Policy Scope

inv-14: Medically Necessary Services (per EPSDT) — definition and intent of medically necessary services

Definition (EPSDT)Services or treatments ordered by an examining physician or other qualified healthcare professional intended to diagnose, correct, or significantly ameliorate defects, physical and mental illnesses, and health conditions under the EPSDT program

Purpose — 'correct' or 'ameliorate'To optimize a health condition, compensate for a health problem, prevent serious medical deterioration, or prevent development of additional health problems

Ordering requirementMust be ordered by an examining physician or other qualified healthcare professional (e.g., nurse practitioner, physician assistant)

Clinical intentIntended to diagnose, correct, or significantly ameliorate defects, illnesses, or health conditions and to support necessary therapeutic interventions for children under EPSDT

Background and Clinical Rationale

Physical and occupational therapy are therapeutic interventions intended to improve, restore, or prevent worsening of physical function that affects activities of daily living due to acute or chronic conditions, injury, or congenital anomalies. Speech therapy diagnoses and treats speech, language, and swallowing disorders and should be performed, at least in part, in the member's dominant language.

The high-level aims of these therapies are to produce clinically significant and measurable improvement in function within a reasonable and medically predictable timeframe, or to prevent significant functional regression when part of a medically necessary program.

Policy Summary

PayerAmbetter Nevada

PolicyPhysical, Occupational, and Speech Therapy Services

Policy CodePolicy CP.MP.49

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain initial authorization and submit a signed plan of care with diagnosis, measurable goals, and planned interventions.

SourceLink

On This Page

Expected to produce measurable improvement or prevent regression; in‑home care only if safely performed at home and transportation is impractical/medically inappropriate.

Step Therapy

Step therapy not specified

No step therapy requirements are specified in this policy.

Documentation Required

Submit POC and supporting documentation for initial and continued authorization

For initial authorization submit the written plan of care (POC) signed by the therapist containing all required elements; for continued authorization submit an updated POC/progress summary signed by the therapist with objective documentation of progress and plan details.

Initial POC must include: diagnosis with date of onset/exacerbation; specific measurable short‑ and long‑term functional goals; planned treatment techniques with amount/frequency/duration; member/caregiver education and HEP; brief history of prior treatment; current level of functioning and barriers; most recent standardized evaluation scores (age equivalency/percent delay/SD when appropriate); clinical observations and prognosis; and member agreement to participate. (Note: standardized scores ≥ 1.5 SD below mean may qualify but not sole criterion.)
For continued authorization provide: updated standardized scores if applicable; objective measures of functional progress versus prior report; summary of response and issues limiting progress; documentation of member/caregiver participation and HEP adherence; brief prognosis with discharge criteria; explanation for POC changes with clinical rationale; prescribed modalities with anticipated frequency/duration; and physician or other qualified healthcare professional signature on the POC or prescription. If home‑based, document that treatment can be safely and adequately performed at home and transportation is impractical/medically inappropriate.

Documentation Required

Required elements of the initial evaluation

The initial formal evaluation must include specified history, systems review, physical assessment, functional level, tests/measurements, potential for improvement, treatment recommendations and education; speech evaluations must be conducted in the member's dominant language.

History of illness or disability and relevant review of systems.
Pertinent physical assessment and tests/measurements of physical function.
Current and previous level of functioning and potential for improvement.
Recommendations for treatment and patient and/or caregiver education.
For speech therapy, evaluation conducted in the member/enrollee's dominant language.

Denial Risk

Triggers that make treatment no longer medically necessary

Treatment is no longer medically necessary and may be discontinued or denied when any listed trigger applies, such as goals achieved, return to baseline, functional plateau, inability to participate, or non‑compliance with HEP/appointments.

Treatment goals achieved (no longer demonstrates functional impairment; returned to baseline; will continue with a HEP; adapted with assistive devices; able to perform ADLs with minimal/no assistance).
A functional plateau has been reached or additional therapy will not be beneficial (failure to benefit/progress despite POC interventions or maximum medical benefit achieved).
Unable to participate in the POC due to medical, psychological, or social complications.
Non‑compliance with a home exercise program and/or lack of participation in scheduled therapy appointments.