ModifiedColorado Rocky Mountain Health PlansPolicy CS164.L

Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech)

Policy governing medical necessity, documentation, evaluation, plan-of-care, continuation, re-evaluation, and discharge criteria for outpatient occupational, physical, and speech therapy services for Colorado Rocky Mountain Health Plans members (state-specific exceptions noted).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech)

Policy CodePolicy CS164.L

Change TypeMaterial additions: non-duplication requirement and speech/language language-of-proficiency criteria

Effective DateNov 1, 2025

Next Review Date

Key ActionProvide a complete evaluation and plan of care with baseline standardized assessments (or documented alternatives) and a referring provider order prior to initial therapy evaluation.

SourceLink

POLICY UPDATE CHANGES

Added language that services must not duplicate concurrent services by another therapy type and must provide different treatment goals, plans, and modalities.

Added specific Speech and Language Considerations for bilingual/multilingual speakers and testing/delivery language requirements.

Removed content/language pertaining to the state of Louisiana.

Updated reference link to reflect the current policy title for Cognitive Rehabilitation and Coma Stimulation.

Added Clinical Evidence section and updated Description of Services and References.

Removed Benefit Considerations section.

6 monthsmax initial auth

every 6 monthsre-eval freq

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

standardizedassessments required

must include PCP/specialist referralreferral requirement

04/01/2026policy history

Coverage Criteria and Rationale

Coverage Rationale / Language and Duplication Criteria

Covered when ALL of the following are met

InterQual and clinical necessity: Services meet InterQual LOC: Outpatient Rehabilitation & Chiropractic medical necessity criteria and are not cognitive therapy (cognitive therapy is governed by a separate policy).

InterQual referenced as primary clinical criteria

Evaluation documentation: A referring provider (PCP or appropriate specialist) is on file unless exempted by state rule, and the therapy evaluation report includes medical history; comparison of prior versus current function; description of functional impairment and its impact on health, safety, or independence; a clear ICD-10 diagnosis; a reasonable prognosis with potential for meaningful progress; and baseline objective measurements (current standardized assessments or documented task-analysis alternatives).

See required elements for initial therapy evaluation

Plan of care: A plan of care based on evaluation results that documents the functional or physical impairment, specific measurable short- and long-term functional goals, and the prescribed treatment frequency, duration, and anticipated session length is provided at initial authorization.

POC must be functional, measurable, attainable, and time-based

ref":"b0_0","title":"Medical necessity and documentation criteria"},{

ref":"b0_1","citations":["3","29","21"],"title":"Coverage Rationale / Language and Duplication Criteria","intro":"Coverage is informed by service definitions and the Coverage Rationale; additional constraints apply as described below.","nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"Non-duplication\",\"text\":\"Services must not duplicate concurrent services provided by another type of therapy (e.g., speech, physical, or occupational therapy) and must provide different treatment goals, plans, and therapeutic modalities.\",\"threshold\":\"\",\"note\":\"Relocated Coverage Rationale language\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Speech/Language for limited English proficiency\",\"text\":\"For individuals with limited English proficiency or bilingual/multilingual speakers: culturally and linguistically adapted norm‑referenced testing in all languages the individual is exposed to is required; deficits and delivery of services must be in the language of the individual's highest proficiency, and equivalent proficiency in both languages should not be assumed.\",\"threshold\":\"\",\"note\":\"Speech and language considerations added to Coverage Rationale\",\"children\":[]}"]}]}{

This policy does not apply to cognitive therapy. For outpatient cognitive therapy, refer to the Medical Policy titled Cognitive Rehabilitation and Coma Stimulation.

The prior "Benefit Considerations" section has been removed from this policy. Content that formerly appeared in that section has been relocated into other policy sections (for example, Coverage Rationale and Speech and Language Considerations) or removed as noted in the Policy History.

Services that are duplicates of concurrent therapy provided by another therapy type (for example, identical goals and modalities provided simultaneously by speech, physical, or occupational therapy) must not be billed as separate covered services and risk denial. Continuation of therapy without objective demonstration of progress, without an updated plan of care, or when therapist skill is no longer required is appropriate for discharge as described in the Discharge Criteria.

The HCPCS code S8990 denotes physical or manipulative therapy performed for maintenance rather than restoration. Use of S8990 should be supported by documentation that clearly distinguishes maintenance intent from restorative/skilled therapy and demonstrates that the service meets plan coverage rules; depending on benefit terms, pure maintenance-only therapy may be considered non‑covered.

Applicable Codes and Coding Notes

Speech evaluation and treatment codes (excerpt)CPT

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual.
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals.
92521	Evaluation of speech fluency (e.g., stuttering, cluttering).
92522	Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria).

Modalities and related codes (excerpt)CPT

92523	Evaluation of speech sound production; with evaluation of language comprehension and expression.
92524	Behavioral and qualitative analysis of voice and resonance.
92526	Treatment of swallowing dysfunction and/or oral function for feeding.
92609	Therapeutic services for the use of speech-generating device, including programming and modification.
92610	Evaluation of oral and pharyngeal swallowing function.
96105	Assessment of aphasia with interpretation and report, per hour.
97012	Traction, mechanical.
97014	Electrical stimulation (unattended).
97016	Vasopneumatic devices.
97018	Paraffin bath.

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Therapy evaluation, treatment, and assistive device codes (excerpt)CPT

97110	Therapeutic exercises, each 15 minutes.
97112	Neuromuscular reeducation, each 15 minutes.
97113	Aquatic therapy with therapeutic exercises.
97116	Gait training (includes stair climbing).
97139	Unlisted therapeutic procedure (specify).
97140	Manual therapy techniques, each 15 minutes.
97150	Therapeutic procedure(s), group (2 or more individuals).
97161	Physical therapy evaluation: low complexity.
97162	Physical therapy evaluation: moderate complexity.
97163	Physical therapy evaluation: high complexity.

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Applicable CPT CodesCPT

97168	Re-evaluation of occupational therapy established plan of care
97530	Therapeutic activities, direct (one-on-one), each 15 minutes
97535	Self-care/home management training, direct one-on-one, each 15 minutes
97542	Wheelchair management, each 15 minutes
97750	Physical performance test or measurement with written report, each 15 minutes
97755	Assistive technology assessment with written report, each 15 minutes
97760	Orthotic(s) management and training, initial encounter, each 15 minutes
97761	Prosthetic(s) training, initial prosthetic encounter, each 15 minutes
97763	Orthotic(s)/prosthetic(s) management and/or training, subsequent encounter, each 15 minutes
97799	Unlisted physical medicine/rehabilitation

Applicable HCPCS/S/G CodesHCPCS

G0281	Electrical stimulation (unattended) for chronic pressure/arterial/diabetic/venous ulcers after 30 days conventional care
G0283	Electrical stimulation (unattended) for indications other than wound care
S8948	Low-level laser application, each 15 minutes (constant provider attendance)
S8990	Physical or manipulative therapy performed for maintenance rather than restoration
S9129	Occupational therapy, in the home, per diem
S9131	Physical therapy, in the home, per diem
S9152	Speech therapy, re-evaluation

Re-evaluation frequency

Re-evaluation frequencyRe-evaluations must be completed at least once every six months (or more frequently if required by state regulation); more frequent re-evaluations only for significant change in functional level

Required contentRe-evaluation must include current standardized assessment scores or other objective measures, description of current deficits, progress vs baseline, updated POC and prognosis

POC currencyUpdated plan of care/progress summary must not be older than 90 days

Re-evaluation typical time

Typical face-to-face timeA formal re-evaluation typically requires 30 minutes face-to-face with the patient and/or family

Provider Requirements, Documentation, and Authorization

Prior Authorization

Authorization requirements and duration — initial authorizations and InterQual reference for up to six months

Prior authorization may be required. Upon clinical review and when appropriate, Colorado Rocky Mountain Health Plans (CRMH) may authorize therapy services based on InterQual® criteria for up to six months in accordance with generally accepted standards of practice. Services must not duplicate another therapy provided concurrently (e.g., speech, physical, occupational); concurrent therapies must have different treatment goals, plans, and therapeutic modalities. Documentation requirements below are used in addition to InterQual® to assess medical necessity but do not guarantee coverage.

Initial authorizations may be for up to 6 months per InterQual® review and clinical discretion.
Do not bill services that duplicate goals/modalities of another concurrent therapy type.

Prior Authorization

Prior authorization may be required for listed HCPCS/S codes

Prior authorization may be required for certain HCPCS/S codes listed in the Applicable Codes section. Verify authorization requirements prior to providing services.

Background and Evidence

Habilitation, rehabilitation, and maintenance therapies are evaluated using standardized clinical criteria (referenced InterQual® LOC: Outpatient Rehabilitation & Chiropractic) and by documented evidence of functional impairment, potential for meaningful improvement, and need for skilled therapist intervention. Rehabilitative services are intended to improve, adapt, or restore impaired function; habilitative services help a person keep, learn, or improve daily living skills; and maintenance therapy is intended to prevent deterioration or preserve function when further improvement is not reasonably expected. Clinical review relies on initial evaluation, objective baseline measurements, an individualized plan of care with measurable goals, and periodic re‑evaluation to determine ongoing medical necessity.

Key Definitions

InterQual LOC: Outpatient Rehabilitation & Chiropractic

Referenced toolInterQual® LOC: Outpatient Rehabilitation & Chiropractic is used to determine medical necessity for outpatient rehabilitation and chiropractic services

RoleInterQual criteria referenced as primary clinical coverage criteria for habilitation, rehabilitation, and maintenance services

Exclusion noteThis policy does not apply to cognitive therapy; refer to Cognitive Rehabilitation and Coma Stimulation policy for cognitive services

Rehabilitative services definition

DefinitionRehabilitative services are intended to improve, adapt, or restore functions impaired or permanently lost due to illness, injury, loss of a body part, or congenital abnormality

Goals

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech)

Policy CodePolicy CS164.L

Change TypeMaterial additions: non-duplication requirement and speech/language language-of-proficiency criteria

Effective DateNov 1, 2025

Next Review Date

Key ActionProvide a complete evaluation and plan of care with baseline standardized assessments (or documented alternatives) and a referring provider order prior to initial therapy evaluation.

SourceLink

On This Page

PurposeAssess changes in functional or medical status and revise plan of care as needed

When performedPerformed when there is documented change in functional status or significant change to the plan of care

Examples include: G0281, G0283, S8948, S8990, S9129, S9131, S9152.

Documentation Required

Provider action: referral/order requirement

A referral/order from an appropriate prescribing provider (PCP or specialist: MD, DO, PA, NP) for the therapy evaluation must be on file prior to completing the initial evaluation unless state rules exempt this requirement.

Obtain and retain the referring provider’s order/referral before performing the initial evaluation.
Ensure the order includes the reason for referral and diagnosis (ICD-10).

Documentation Required

Required evaluation, POC, and session documentation — initial evaluation components and plan-of-care requirements

Initial evaluation must document the individual’s medical history, diagnosis (with ICD-10), comparison of prior and current function, a reasonable prognosis, and baseline objective measurements using standardized assessments when possible. If standardized tests cannot be completed due to medical status, provide task analysis, checklists, caregiver reports/interviews, and clinical observation.

Include current standardized assessment scores, age equivalents, percent functional delay, or criterion-referenced scores as applicable.
Document how standardized assessments relate to the long- and short-term goals.
If standardized assessments are not feasible, provide in-depth clinical task analysis and alternative objective information.

Documentation Required

Provider action: include complete Plan of Care with initial authorization

The initial authorization request must include a Plan of Care (POC) developed from the evaluation. The POC must state the functional/physical impairment, measurable short- and long-term goals tied to the diagnosed condition, and treatment frequency, duration, and anticipated session length.

Goals must be functional, measurable, attainable, time-based, and relate to individual-specific skills.
Specify treatment frequency, duration, and anticipated length of each session in the POC.

Documentation Required

Provider action: documentation required for continuation requests

For continuation requests, include prior weeks/visits authorized and attended, current status compared to baseline and prior progress, objective measures demonstrating continued impairment, and justification of need for continued skilled services.

Report weeks of therapy previously authorized and visits attended.
Provide objective measures using the same assessments whenever possible to show progress or continued impairment.

Documentation Required

Re-evaluation and documentation requirements — what must be documented at re-eval (changes, updated occupational profile, goals)

Re-evaluations must occur at least every six months (or more frequently if state rules require) and must include updated standardized assessment scores, comparison to baseline, number of visits authorized/attended, compliance with home program, updated POC with measurable time-based goals, brief prognosis and discharge criteria. Re-evaluations older than 90 days are not acceptable for continuation.

Include date of last evaluation, number of visits authorized and attended, and objective demonstration of progress toward each goal.
Updated POC/progress summary must not be older than 90 days; meaningful updates are required — mere percentage completion of goals is insufficient.

Documentation Required

Required documentation for treatment sessions

All treatment session notes must include the date, specific treatments that correspond to billed CPT codes, accurate session length, patient response, skilled ongoing reassessment, objective measurable progress toward goals, any changes to the POC, caregiver involvement and feedback, and the treating provider’s signature and date.

Document treatments provided that match CPT codes billed and the exact time spent in skilled therapy.
Record objective measurable progress using consistent methods and note any problems or POC changes.

Documentation Required

Group therapy documentation — required elements for group therapy sessions

Group therapy documentation must include the prescribing provider’s order, an individualized treatment plan with frequency/duration and individualized goals, the supervising licensed therapist’s name/signature, treatment techniques used and how they restore function, session length, setting/location, and number of clients in the group.

Maintain individualized goals for each participant even when therapy is delivered in a group setting.
Ensure supervising therapist documents techniques and supervision provided.

Documentation Required

Feeding and swallowing documentation — required elements for dysphagia evaluations

Feeding and swallowing (dysphagia) evaluations must include interview/case history, medical/clinical records (including medication impact), physical exam, prior screenings/assessments, collaboration with other providers/caregivers, and assessment outcomes such as description of swallow physiology, diagnosis, route of nutrition, intervention recommendations, and prognosis.

Document medical stability, cognitive and nutritional status, psychosocial/environmental factors that affect candidacy for treatment.
Include clear recommendations and prognosis for improvement when submitting a feeding/swallowing evaluation.

Denial Risk

Documentation and duplication risks — requests lacking required documentation may be denied

Requests lacking the required documentation (evaluation, POC, progress notes, re-evaluations) or requests that do not demonstrate skilled services and measurable progress are at risk for denial. Additionally, requests for services duplicative of another therapy type (same goals/modalities) are at risk for denial.

Missing or outdated POC (older than 90 days) or lack of meaningful updates may lead to denial.
Services duplicative of another concurrent therapy (identical goals/modalities) may be denied.

Services involve goals an individual can reach in a reasonable period with assistance of a therapist or supervised therapy assistant

ScopeMay include occupational, physical, or speech therapy

Habilitation services definition

DefinitionHabilitation services help a person keep, learn, or improve skills and functioning for daily living

ExamplesIncludes therapy for developmental delays (e.g., child not walking or talking at expected age) and may include PT, OT, speech-language pathology

SettingsProvided in a variety of inpatient and/or outpatient settings for individuals with disabilities

Maintenance therapy definition

DefinitionMaintenance therapy seeks to prevent deterioration or maintain function when further clinical improvement cannot reasonably be expected

Nature of careWhen treatment is supportive rather than corrective, it is considered maintenance therapy

Documentation implicationUse of S8990 indicates maintenance; documentation should support maintenance vs restorative intent and justification for ongoing skilled services