Colorado Rocky Mountain Health Plans Habilitation/Prior Auth

Coverage and Medical Necessity Criteria

Medical Necessity and Authorization Criteria

Covered when ALL of the following are met and required documentation is submitted:

Core coverage requirements: Prior authorization obtained before therapy is provided; therapy delivered by a licensed, appropriate therapist; therapy evaluation report and discipline-specific plan of care (POC) submitted with authorization request; services meet the Medical Necessity definition; re-evaluations completed at least once every five (5) months as applicable.

If prior authorization is not on file before therapy is provided, the therapy claim will be denied. PCP must submit initial evaluation and re-evaluation requests unless an authorization for an initial evaluation is on file allowing the servicing provider to submit.

Documentation specifics: The therapy evaluation report must be discipline-specific and include: date of initial evaluation; member name, age, and birthdate; brief medical history with onset date and any prior therapy; relevant review of systems; member language knowledge/exposure; description of functional impairment and its impact on health, safety, and/or independence; comparison of prior level of function to current level (as applicable); clear diagnosis and reasonable prognosis including potential for meaningful and significant progress; baseline objective measurements and standardized assessment scores; and a POC signed and dated by the referring provider and treating therapist.

Baseline and current function must be submitted for all unmet goals. Standardized tests administered must correspond to identified delays; if standardized assessment cannot be completed, provide task analysis and objective clinical information.

Evaluation and progress requirements: Updated POC/progress summary must be no older than 90 days; a comprehensive re-evaluation must be completed at least once every five (5) months and include current standardized assessment scores, age equivalents, percentage of functional delay, criterion-referenced scores, or other objective information as appropriate.

A revised POC that lacks a meaningful update by the treating therapist will not be accepted; simple percentage toward goals alone is insufficient to justify continued services.

Visit approval logic: Visit frequency and duration approvals are based on standardized assessment severity: Mild (−1 to −1.5 SD or score 85–78): up to 1 visit/week, up to 26 weeks; Moderate (−1.5 to −2 SD or score 77–71): up to 2 visits/week, up to 26 weeks; Severe/Profound (>2 SD or score ≤70): up to 3 visits/week, up to 13 weeks.See severity categories from standardized assessments

Approvals are considered on a case-by-case basis. If continued need is anticipated after authorization ends, follow the re-evaluation process to request additional visits.

Limitations and exclusions apply. Services that are duplicative of other billed services, services that do not meet the Medical Necessity criteria, or services provided to members who do not meet eligibility requirements will be excluded. Routine activities such as developing or updating the plan of care, mileage/travel expenses, securing/installing/maintaining therapy equipment, services not listed on the fee schedule, telephone communications (except as allowed by the telemedicine policy), time supervising assistants or students, treatment visits on the same day as an evaluation, and multiple same-day AAC fitting/adjustment/training visits (speech only) are specifically listed as exclusions.

The HCPCS code S8990 is defined as "physical or manipulative therapy performed for maintenance rather than restoration." Use of S8990 denotes that the service is maintenance in intent; such maintenance therapy may not meet the policy's restorative Medical Necessity criteria and therefore may be excluded from coverage under this policy.

Services that do not meet the Medical Necessity criteria or that duplicate other billed services will be denied or excluded. The policy explicitly lists examples of services and activities that do not meet coverage, including non-covered administrative or travel-related activities, services not on the fee schedule, unsupervised time spent with assistants or students, same-day treatment visits with evaluations, and other specified limitations such as multiple same-day AAC visits for speech therapy.

CPT / HCPCS Codes, Severity and Time Standards

Applicable CPT CodesCPT

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).
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.

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Speech-language CPT CodesCPTCovered

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).
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.

Modalities CPT CodesCPTCovered

97012	Traction, mechanical.
97014	Electrical stimulation (unattended).
97016	Vasopneumatic devices.
97018	Paraffin bath.
97022	Whirlpool.
97024	Diathermy (e.g., microwave).
97026	Infrared.
97028	Ultraviolet.
97032	Electrical stimulation (manual), each 15 minutes.
97033	Iontophoresis, each 15 minutes.

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Physical Therapy CPT CodesCPTCovered

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.
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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Occupational and Assistive Technology CPT CodesCPTCovered

97165	Occupational therapy evaluation, low complexity.
97166	Occupational therapy evaluation, moderate complexity.
97167	Occupational therapy evaluation, high complexity.
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 orthotic encounter, each 15 minutes.

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HCPCS and Site-specific CodesHCPCSCovered

G0281	Electrical stimulation (unattended) for chronic wounds not demonstrating measurable healing after 30 days of conventional care, as part of a therapy plan of care.
G0283	Electrical stimulation (unattended) for indications other than wound care, as part of a therapy plan of care.
S8948	Application of a modality; low-level laser; each 15 minutes.
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.

Severity categories from standardized assessments

MildStandard deviation -1 to -1.5 (score 85–78); approval: up to 1 visit/week, up to 26 weeks (case-by-case)

ModerateStandard deviation -1.5 to -2 (score 77–71); approval: up to 2 visits/week, up to 26 weeks (case-by-case)

Severe/Profound>2 standard deviations from mean (score ≤70); approval: up to 3 visits/week, up to 13 weeks (case-by-case)

Wound care electrical stimulation criterion

Wound-care electrical stimulation indicationNot demonstrating measurable signs of healing after 30 days of conventional care for chronic Stage III/IV pressure ulcers, arterial, diabetic, or venous stasis ulcers; as part of a therapy plan of care (G0281)

Prior Authorization, Documentation, and Billing Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for initial evaluations, re-evaluations, initial therapy visits, and continuation visits. If a prior authorization is not on file before therapy is provided, the therapy claim will be denied.

PA required for initial evaluations and re-evaluations (every 5 months)
If no PA on file prior to service, claim will be denied

Note

Verify Plan-Specific Prior Authorization

Verify plan-specific prior authorization and benefit requirements before submitting requests. Always check the member's federal, state, or contractual plan documents for any differences from this policy; those requirements govern in the event of a conflict.

Confirm plan-specific PA rules and any state- or contract-level mandates
Reference federal, state, or contractual benefit requirements which govern if different from this standard policy

Clinical Background and Scope

Habilitation, rehabilitation, and maintenance therapies may all be clinically appropriate in different circumstances, but coverage depends on meeting the policy's Medical Necessity requirements and documentation standards. The policy distinguishes restorative therapy from maintenance (e.g., HCPCS S8990 indicates maintenance) and requires objective evaluation data, a discipline-specific plan of care, and ongoing re-evaluation to justify continued restorative services. Specific modality codes (including wound-related electrical stimulation G0281 and other modality and assistive-technology codes) are included when they are part of an appropriate therapy plan of care that meets the medical necessity criteria.

Key Definitions and Evaluation Complexity

Medically Necessary / Medical Necessity — definition and required elements

DefinitionCare, goods, or services necessary to protect life, prevent significant illness or disability, or alleviate severe pain; individualized, specific, consistent with symptoms or confirmed diagnosis, not experimental, and the least intensive effective service

Consistency with standardsMust be consistent with generally accepted professional medical standards and not experimental or investigational

Appropriate level and settingReflective of the level of service that can be safely furnished and for which no equally effective more conservative or less costly treatment is available statewide

Physical/Occupational evaluation complexity levels

Low complexity (PT/OT)PT: 97161 — history with no impacting comorbidities; exam addresses 1–2 elements; stable presentation; low complexity decision-making; typically 20 minutes face-to-face

Policy Revision History

2026-03-01reference_updateLatest

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

2025-11-01references_updated_archived_prior_version

Updated References section to reflect the most current information and archived previous policy version CS164FL.L.

OpenPayer

Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Florida Only)