CurrentCentenePolicy CP.MP.49

Physical, Occupational, and Speech Therapy Services Coverage Criteria

Governs medical necessity, authorization, continuation, reevaluation, and discontinuation criteria for outpatient or home-based physical, occupational, and speech therapy services for members of Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyPhysical, Occupational, and Speech Therapy Services Coverage Criteria

Policy CodePolicy CP.MP.49

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a formal evaluation and a signed plan of care documenting criteria and measurable goals for initial and continued authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial/Continued/Reeval/DiscontCriteria categories defined

Dominant languageSpeech evaluation language

6 monthsReevaluation interval

≥1.5 SDStd. score threshold

Coverage Criteria for Therapy Services

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

Initial Authorization: B. 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. The evaluation must include: history of illness/disability; relevant review of systems; pertinent physical assessment; current and previous level of functioning; tests or measurements of physical function; potential for improvement; recommendations for treatment and patient and/or caregiver education. For speech therapy, the formal evaluation must be conducted in the member/enrollee's dominant language.

Initial Authorization: C. 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 therapy drills which do not require a licensed/certified professional's feedback are not covered services.

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

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

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

Initial Authorization: G. Treatment is expected to either: produce clinically significant and measurable improvement in functioning within a reasonable, medically predictable period, or prevent significant functional regression as part of a medically necessary program.

Initial Authorization: H. If treatment is to be performed in the home, the treatment can be safely and adequately performed in the home environment and the diagnosed impairment or condition makes transportation to an outpatient rehabilitation facility impractical or medically inappropriate.

Continuation Therapy

Continued authorization is considered medically necessary when ALL of the following are met:

Continuation: A. Treatment progress is clearly documented in an updated POC/current progress summary signed by the therapist and submitted at the end of each authorization period and/or when additional visits are requested. Documentation must include: updated standardized evaluation scores (with age equivalency, percent of functional delay, or SD score, if applicable); objective measures of functional progress relative to each treatment goal with comparison to prior report; summary of response to therapy and any issues limiting progress; documentation of member/caregiver participation; documentation of participation/adherence with a HEP if applicable; a brief prognosis with clearly established discharge criteria; explanation and clinical rationale for any significant POC changes; prescribed treatment modalities with anticipated frequency and duration; and physician or other qualified clinician signature on the POC or prescription. IFSP/IEP or attestation should be submitted when applicable to verify no duplication for children.

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

Reevaluation

Formal reevaluation up to once every six months is considered medically necessary when ALL of the following are met:

Reevaluation: A formal reevaluation by a licensed/registered therapist is considered medically necessary up to once every six months when there is documentation of: new clinical findings or a significant change in condition that was not anticipated in the POC, or failure to respond to therapeutic interventions outlined in the POC.up to once every 6 months

Reevaluation is not required to assess need for continued treatment but is considered medically necessary under these triggers.

Discontinuation / No Longer Medically Necessary

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

No Longer Medically Necessary: A. 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 HEP; has adapted to impairment with assistive devices; is able to perform ADLs with minimal to no assistance. B. A functional plateau in progress has been reached, or additional therapy will no longer be beneficial (a denial for failure to benefit/progress may be made when therapeutic interventions per the POC have been applied and maximum medical benefit achieved). C. Member is unable to participate in the POC due to medical, psychological, or social complications. D. Non-compliance with a HEP and/or lack of participation in scheduled therapy appointments.

Treatments may be re-instituted if documented regression occurs.

Therapy is considered not medically necessary when treatment goals have been achieved or when further therapy will not provide benefit. Examples include when the member has returned to baseline or no longer demonstrates functional impairment, is maintaining function with a home exercise program or assistive devices, or is able to perform ADLs with minimal or no assistance. The policy also states that services may be discontinued when a functional plateau has been reached or additional therapy will no longer be beneficial, when the member is unable to participate due to medical/psychological/social complications, or when there is non‑compliance with the home exercise program or scheduled appointments.

Provider Requirements and Actions

Prior Authorization

Prior Authorization Required

Authorization requires documentation of a formal evaluation and a signed plan of care (POC). Initial and continued authorization requests must include the therapist-conducted evaluation and the written POC signed by the therapist.

Formal evaluation conducted by a licensed/registered speech, occupational, or physical therapist must be submitted.
Written POC signed by the therapist must include diagnosis with date of onset/exacerbation, measurable short- and long-term functional goals, planned treatment techniques (amount, frequency, duration), education/home program, history of prior treatment, current level of functioning, standardized evaluation scores when applicable, clinical observations/prognosis, member agreement to POC.
For continued authorization: updated POC/current progress summary signed by the therapist at the end of each authorization period — include updated standardized scores, objective measures of progress vs goals, summary of response and barriers to progress, documentation of participation/adherence to HEP, prognosis with discharge criteria, explanation/rationale for POC changes, prescribed modalities with frequency/duration, and physician or qualified healthcare professional signature on the POC or prescription.

Step Therapy

No step therapy requirements are specified for outpatient speech, occupational, or physical therapy services under this policy.

Documentation Required

Required Evaluation and Plan of Care Documentation

The written plan of care (POC) must be discipline-specific and signed by the therapist. The POC must document diagnosis and onset date, measurable short- and long-term functional goals tied to the diagnosed condition, detailed planned interventions (amount, frequency, duration), member and caregiver education including a home exercise program, brief history of prior treatment, description of current level of functioning and any conditions impeding benefit, most recent standardized evaluation scores when appropriate, clinical observations and prognosis, and member agreement to participate.

Include age-equivalent, percent of functional delay, or SD score for standardized measures when appropriate.
Standardized scores ≥ 1.5 SD below the mean may support medical necessity but cannot be the sole criterion.

Denial Risk

Risk of Denial for Failure to Benefit

Services may be denied or discontinued if there is lack of documented progress, a functional plateau, failure to benefit despite appropriate therapy per the POC, non‑compliance with the home exercise program, or inability to participate in the POC due to medical/psychological/social issues.

Denial may be made when maximum medical benefit has been achieved or condition/developmental deficit fails to improve despite application of therapeutic interventions per the POC.
Failure to document participation or adherence to the POC/HEP can result in denial or discontinuation.

Background

Physical and occupational therapy interventions are therapeutic services intended to restore, improve, or prevent worsening of physical function and the ability to perform activities of daily living across a range of conditions, including acute injury, chronic disease, congenital anomalies, or disability. The policy also recognizes speech therapy as the service that diagnoses and treats speech, language, and swallowing disorders, and requires that speech evaluations be conducted at least partly in the member's dominant language when applicable. Collectively, these services are provided to produce measurable functional improvement, prevent significant regression, or address likely loss of function within a reasonable, medically predictable period of time.

Definitions

Medically Necessary Services — inv-13

DefinitionMedically Necessary Services are services or treatments ordered by an examining physician or other qualified healthcare professional intended to diagnose, correct, or significantly ameliorate defects, illnesses, and health conditions

ProvidersIncludes orders from physicians and other qualified professionals (e.g., nurse practitioners, physician assistants)

EPSDT ConsiderationFor EPSDT, medically necessary services include those to correct or ameliorate conditions in children as part of the Early and Periodic Screening, Diagnosis and Treatment program

Speech therapy — inv-14

ScopeSpeech therapy includes services for diagnosis and treatment of speech and language disorders and for diagnosis and treatment of swallowing disorders (dysphagia)

Evaluation language requirementThe member's evaluation should be conducted at least partially in the member's dominant language; those who speak a language other than English should be tested in their primary language

PurposeDesigned to correct, ameliorate, restore, or rehabilitate speech/language communication and swallowing disorders resulting from chronic medical conditions, congenital anomalies, or injuries

OpenPayer

Physical, Occupational, and Speech Therapy Services Coverage Criteria

Coverage Criteria for Therapy Services

Coding Notes and Thresholds

Provider Requirements and Actions

Background

Definitions