CurrentCentenePolicy CPMP.49

Physical, Occupational, and Speech Therapy Services

Governs authorization and medical necessity criteria for initial, continued, reevaluation, and discontinuation of outpatient or home-based physical, occupational, and speech therapy for Centene-affiliated health plans. Affects providers requesting therapy services and prior authorization reviewers.

Policy Summary

PayerCentene

PolicyPhysical, Occupational, and Speech Therapy Services

Policy CodePolicy CPMP.49

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a therapist-signed plan of care and documented evaluation with required elements for initial and continued prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial/Continued/Reeval/DiscontAuthorization stages addressed

Includes criteriaHome-based services

Dominant languageSpeech evaluation language

≥1.5 SDStandardized score use

Coverage Criteria for Outpatient and Home Therapy

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Not Medically Necessary / Discontinuation

Therapy is no longer medically necessary when ANY of the following apply:

Discontinuation/Not medically necessary: a) Goals in the POC have been achieved or the member no longer demonstrates functional impairment; b) Member has returned to baseline function; c) A functional plateau has been reached and additional therapy is unlikely to be beneficial; d) Member has adapted to the impairment with assistive equipment or devices; e) Member is able to perform activities of daily living (ADLs) with minimal or no assistance from a caregiver; f) Member is unable to participate in the POC due to medical, psychological, or social complications; g) Non‑compliance with the HEP and/or lack of participation in scheduled therapy appointments.

Reevaluation

Reevaluation authorization:

Reevaluation criteria: A formal reevaluation by a licensed/registered therapist is considered medically necessary up to once every six months when there is documentation of either: new clinical findings or a significant change in condition not anticipated in the POC; OR failure to respond to therapeutic interventions outlined in the POC.once every six months

One of the listed conditions is sufficient to permit reevaluation.

Home-Based Therapy

Home-based therapy eligibility (when ALL are met):

Home therapy criteria: 1) The treatment can be safely and adequately performed in the home environment. 2) The diagnosed impairment or condition makes transportation to an outpatient rehabilitation facility impractical or medically inappropriate.

Both conditions must be met for home-based services.

Certain services are expressly excluded because they do not require professional clinical judgment or are duplicative. Specifically, repetitive therapy drills that do not require licensed or certified professional feedback are not covered. Additionally, therapy that duplicates services provided by other therapy types or duplicates services provided in multiple settings is excluded from coverage.

Functional plateau and failure to benefit are defined as clinical situations in which continued therapy is no longer medically necessary. Examples include when the member has achieved the goals in the plan of care or no longer demonstrates functional impairment, has returned to baseline function, has adapted to the impairment with assistive equipment, or is able to perform ADLs with minimal or no assistance. The policy notes that a functional plateau—where additional therapy will no longer be beneficial—is a reason to discontinue services. Likewise, a failure to benefit or progress may lead to denial when the condition has not improved despite therapeutic interventions provided in accordance with the POC and maximum medical benefit has been achieved. Non‑participation (including inability to participate due to medical, psychological, or social complications) or non‑compliance with a home exercise program are additional non‑coverage rationales.

Scoring and Coding Guidance

Standardized score threshold — inv-08

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

Use limitationSuch a standardized score may not be used as the sole criterion for determining eligibility for initial or continuing treatment services

Documentation expectationMost recent standardized evaluation scores must be included in the therapist-signed plan of care with age equivalency or diagnosis/disability noted

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for outpatient speech, occupational, and physical therapy services. Requests must include an examining physician or authorized provider's order and a formal evaluation by a licensed/registered therapist. The evaluation and submitted documentation must demonstrate the member's diagnosed impairment, baseline functional status, relevant history and assessment, measurable deficits (e.g., ADL/mobility limitations, sensory/motor, cognitive/communication, cardiopulmonary), and the potential for improvement.

Include physician or authorized provider order with request
Attach licensed/registered therapist formal evaluation (see documentation callout)
Home-based treatment requests must document that transportation to outpatient rehab is impractical or medically inappropriate

Documentation Required

Required Evaluation and Plan of Care Documentation

The written plan of care (POC), signed by the treating therapist, must be submitted with initial authorization requests and with each authorization period. The POC must detail measurable short- and long-term functional goals, planned treatment techniques/interventions (including amount, frequency, and duration), standardized evaluation scores, current level of functioning, caregiver education and home exercise program when applicable, prognosis with discharge criteria, documentation of prior treatment, and member agreement to the POC.

POC must include: diagnosis with onset date; history of illness/disability; pertinent physical assessment and review of systems; standardized evaluation scores and age equivalency where applicable
Goals must be specific, measurable, and tied to functional improvement; planned interventions must include amount, frequency, and duration
Progress summaries and updated POC signed by therapist required at end of each authorization period or when requesting additional visits

Denial Risk

Reasons for Discontinuation/Denial

Services may be discontinued or denied when documented criteria indicate lack of medical necessity or failure to meet policy requirements. Denial or discontinuation may be appropriate for lack of documented progress toward measurable goals, attainment of goals or return to baseline function, a sustained functional plateau where further therapy is not beneficial, inability to participate in the POC (medical, psychological, or social complications), non‑compliance with a home exercise program or scheduled appointments, duplication of services, or when therapy goals have been achieved or replaced by a home exercise program.

Denial for “failure to benefit or progress” may be made when therapeutic interventions consistent with the POC have been applied and no clinical improvement is documented
Reinstatement of therapy may occur if a documented regression is reported and the policy criteria are again met
Lack of required documentation (physician order, formal evaluation, signed POC, progress summaries) may result in denial

Definitions

Medically Necessary Services — inv-14

DefinitionServices ordered by an examining physician or other qualified healthcare professional intended to diagnose, correct, significantly ameliorate, restore, rehabilitate, or prevent serious medical deterioration of functional impairments that affect activities of daily living

ScopeIncludes physical, occupational, and speech therapy for treatment of neuromuscular, musculoskeletal, integumentary dysfunctions, communication disorders and swallowing disorders

EPSDT consistencyApplies pursuant to Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for applicable members

Background

Physical and occupational therapy are therapeutic interventions designed to improve, develop, correct, or prevent deterioration of physical functions that affect activities of daily living through targeted rehabilitation techniques. These services aim to restore or prevent worsening of neuromuscular, musculoskeletal, or integumentary function, support safe mobility and independence in ADLs, and prevent significant functional regression as part of a medically necessary program.