Colorado Rocky Mountain Health Plans rehab Coverage Update

Coverage requirements and clinical standards

Reasonable and Necessary Therapy Services

Services are covered when ALL of the following are met:

General medical necessity conditions: Services are accepted standards of medical practice to be a specific and effective treatment for the member's condition; relate directly and specifically to a written treatment plan established before treatment begins; are of such complexity or the member's condition is such that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist; the amount, frequency, and duration of services are reasonable under accepted standards of practice; and the need for skilled care (not solely diagnosis or prognosis) is demonstrated.

Based on Medicare Benefit Policy Manual guidance (see referenced Medicare manuals and Chapter 15 guidance).

Inpatient Rehabilitation Facility (IRF) Criteria

IRF admission coverage requires ALL of the following at time of admission:

IRF admission criteria: Patient requires active and ongoing therapeutic intervention of multiple therapy disciplines (Physical Therapy, Occupational Therapy, Speech-Language Pathology, or prosthetics/orthotics), one of which must be Physical or Occupational Therapy; requires an intensive rehabilitation therapy program (generally at least 3 hours per day on at least 5 days per week, or at least 15 hours of intensive therapy within a 7 consecutive calendar day period beginning with the date of admission); is reasonably expected to actively participate in and benefit significantly from the intensive rehabilitation therapy program at the time of admission; requires physician supervision by a rehabilitation physician with face-to-face visits at least 3 days per week during the IRF stay; and requires an intensive and coordinated interdisciplinary approach to providing rehabilitation.>= 3 hours/day on >=5 days/week OR >= 15 hours within 7 consecutive days; physician face-to-face visits >= 3 days/week

Per Medicare Benefit Policy Manual IRF criteria.

Skilled Nursing Facility Coverage

Skilled Nursing Facility coverage:

SNF coverage conditions: Inpatient skilled nursing facility care (including room and board, skilled nursing care, and other customarily provided services) is covered when required coverage factors are met and documentation supports a skilled level of care.Up to 100 days per benefit period

Refer to Medicare Benefit Policy Manual, Chapter 8 and Medicare Claims Processing Manual guidance.

Long-Term Acute Care Hospital (LTACH) Coverage

LTACH coverage stance:

LTACH determination: LTACHs are Medicare-certified hospitals generally defined by an average inpatient length of stay greater than 25 days; Medicare has no NCD or LCDs for LTACH medical necessity; reviewers use screening instruments and their clinical judgment to make medical review determinations based on documentation in the medical record.Average inpatient LOS > 25 days

Refer to Medicare Program Integrity Manual, Chapter 6, Section 6.5.1 and CMS definitions.

Coverage when no Medicare NCD/LCD exists

Where no Medicare NCD or LCD exists for a service (e.g., LTACH or certain therapy services), coverage determinations rely on documentation and clinical judgment:

Reviewer determination when no NCD/LCD: The reviewer applies screening instruments and clinical judgment to make medical review determinations based on the documentation in the medical record; if no NCD/LCD is found after searching the Medicare Coverage Database and related CMS documents, apply the Coverage Rationale criteria and supporting documentation.N/A

See Medicare Program Integrity Manual and CMS Related Documents guidance.

Apply LCD/LCA when available

When LCDs/LCAs exist for specific therapy modalities or settings, compliance with those LCDs/LCAs is required:

Apply applicable LCD/LCA: If an LCD or LCA exists for a specific therapy modality or setting (for example outpatient rehabilitation, aqua/pool/hydrotherapy, or other contractor-specific policies), follow that contractor's LCD/LCA for coverage and billing determinations.N/A

Refer to the CMS Related Documents table for contractor-specific LCD/LCA references and applicable billing/coding LCAs.

Use of internal coverage criteria

Policy use and internal criteria application

Policy application: Medicare Advantage Policies are used to support UnitedHealthcare coverage decisions and, where Medicare source materials are absent or allow flexibility, UnitedHealthcare may apply internal coverage criteria developed from evaluation of clinical evidence and guidelines.

Where conflicts exist, Medicare source materials and the member-specific benefit plan document supersede this policy; providers must retain documentation to support coverage.

Services that are intended for the member's general good and welfare — such as general exercise programs to promote overall fitness or flexibility, activities provided primarily for diversion or general motivation, and any services not furnished under an established therapy plan of care or by appropriately qualified/supervised staff — are not payable as Therapy Services. These exclusions reflect Medicare guidance that such activities do not meet the requirements for covered, skilled Therapy Services and therefore are not reimbursable under the therapy benefit.

Also excluded are services that do not meet the Medicare definition of a skilled therapy service because they can be safely and effectively performed without the skill or supervision of a qualified therapist; furnishing such services does not convert them to covered skilled therapy even if a therapist provides them.

Massage therapy is excluded from coverage unless it is provided as part of a multi-modality authorized treatment plan that is appropriate to the patient's diagnosis and has a licensed therapist in attendance. If massage is included only as a standalone or uncoordinated service, it does not meet the Medicare criteria for covered Therapy Services.

When determining coverage for massage as part of a treatment plan, providers must ensure documentation demonstrates the clinical necessity and that massage is integrated with other skilled interventions under the plan of care.

Benefit coverage for health services is determined by the member-specific benefit plan document and applicable law. In the event of any conflict between this policy and the member's plan, the member-specific plan document supersedes this policy. Providers should verify individual member benefits and, when necessary, contact customer service or reference the Administrative Guide for plan-specific coverage determinations.

Services that can be self-administered or that can be safely and effectively furnished by unskilled personnel are not considered skilled Therapy Services and therefore are not reasonable and necessary even if delivered by a therapist. The determination of whether a service is skilled is based on the need for the therapist's skills, not solely on who provides the service.

Claims for services that do not require therapist skill or appropriate supervision are subject to denial; documentation must support that skilled care was required and delivered for the billed services.

Further examples of non-covered activities include: vocational or prevocational assessment and training that is solely related to specific employment opportunities, work skills, or work settings — these services are excluded when their primary purpose is job preparation rather than treating a functional impairment.

Additional non-covered examples are passive rehabilitation for mandibular hypomobility (for which Medicare has no national coverage determination) and other services provided only for diversion or motivation. Providers should refer to the Medicare Benefit Policy Manual sections cited for specific exclusions and apply clinical documentation to justify any services billed as Therapy Services.

Services that do not meet Medicare's therapy criteria — including activities that promote fitness, diversionary activities, and vocational training for employment purposes — must not be billed as skilled Therapy Services and are not payable under the therapy benefit.

Applicable procedure and billing codes

Rehab and therapy CPT codes (part 1)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.
92526	Treatment of swallowing dysfunction and/or oral function for feeding.
97012	Application of a modality to 1 or more areas; traction, mechanical.
97016	Application of a modality to 1 or more areas; vasopneumatic devices.
97018	Application of a modality to 1 or more areas; paraffin bath.
97022	Application of a modality to 1 or more areas; whirlpool.
97024	Application of a modality to 1 or more areas; diathermy (e.g., microwave).
97026	Application of a modality to 1 or more areas; infrared.
97028	Application of a modality to 1 or more areas; ultraviolet.

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Rehab and therapy CPT codes (part 2)CPT

97116	Gait training (includes stair climbing).
97124	Massage, including effleurage, petrissage and/or tapotement.
97139	Unlisted therapeutic procedure (specify).
97140	Manual therapy techniques, each 15 minutes.
97150	Therapeutic procedure(s), group (2 or more individuals).
97164	Re-evaluation of physical therapy established plan of care; typically 20 minutes face-to-face.
97168	Re-evaluation of occupational therapy established plan of care; typically 30 minutes face-to-face.
97530	Therapeutic activities, direct (one-on-one), each 15 minutes.

Rehab and therapy CPT and HCPCS codes (part 3)mixed

97533	Sensory integrative techniques, direct one-on-one, each 15 minutes.
97535	Self-care/home management training, direct one-on-one, each 15 minutes.
97537	Community/work reintegration training, direct one-on-one, each 15 minutes.
97542	Wheelchair management, each 15 minutes.
97545	Work hardening/conditioning; initial 2 hours.
97546	Work hardening/conditioning; each additional hour.
97755	Assistive technology assessment with written report, each 15 minutes.
97760	Orthotic(s) management and training, initial orthotic encounter, each 15 minutes.
97761	Prosthetic(s) training, initial prosthetic encounter, each 15 minutes.
97799	Unlisted physical medicine/rehabilitation service or procedure.

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Referenced coding systemsmixed

CPT	Reference to Current Procedural Terminology for definitional purposes.
CMS	Reference to Centers for Medicare and Medicaid Services coding/guidelines.

inv-17: IRF intensive therapy standard

IRF intensive therapy standardAt least 3 hours of therapy per day on at least 5 days per week (or at least 15 hours of intensive rehabilitation therapy within a 7 consecutive calendar day period beginning with the date of admission)

Required disciplinesActive therapeutic intervention of multiple therapy disciplines, one of which must be Physical or Occupational Therapy

Patient participation expectationPatient must be expected to actively participate in and benefit significantly from the intensive program at admission

inv-18: LTACH average length of stay

LTACH average length of stay threshold> 25 days (average inpatient length of stay)

Provider responsibilities, authorization, and documentation

Prior Authorization

Outpatient therapy utilization management

For members in participating states, outpatient therapy utilization management is managed through the Optum Health Solutions Musculoskeletal (MSK) Utilization Management program. Providers must follow the Optum Medicare Outpatient Skilled Therapy (PT/OT/ST) policy and any additional Optum Physical Health Outpatient Rehabilitation Therapy criteria where applicable.

Applies to members in states participating in the Outpatient Therapy Utilization Management Program
Reference Optum MSK Utilization Management materials for prior authorization and utilization rules

Billing Rule

Codes listed for reference; verify authorization per member plan

The codes listed in this policy are provided for reference only. Inclusion of a code does not imply coverage, guarantee payment, or represent a complete list of billable codes. Always verify coverage and prior authorization requirements against the member-specific benefit plan.

Clinical background and policy purpose

Skilled therapy services (physical therapy, occupational therapy, and speech-language pathology) are considered reasonable and necessary when they are specific, effective treatments that require the skills of a qualified therapist (or appropriate supervision) because of the complexity of the service or the patient's condition. Skilled services may be provided to improve a patient's condition, to maintain current function, or to prevent or slow further deterioration.

The key issue in determining medical necessity is whether the skills of a therapist are needed to deliver the intervention; a service is not skilled merely because it is furnished by a therapist. Documentation must demonstrate the skilled need, relate services directly to a written plan of care established before treatment begins, and show that amount, frequency, and duration are reasonable under accepted standards of practice.

Terms and role definitions

inv-33: Skilled Therapy Services

DefinitionServices that require the skills of a therapist (or supervision by one) because of complexity and that cannot be safely and effectively provided by unskilled personnel; not defined solely by who furnishes the service

PurposeMay be necessary to improve, maintain, or slow deterioration of a patient’s condition

Documentation requirementMust be rendered under conditions specified in CMS manuals and supported by the medical record

inv-34: Occupational Therapy

DefinitionOccupational Therapy: Services provided within the scope of occupational therapists necessary for diagnosis and treatment of impairments, functional disabilities, or changes in physical function and health status (Medicare Benefit Policy Manual, Chapter 15, §230.2)

Scope

OpenPayer

Skilled Nursing Facility, Rehabilitation, and Long-Term Acute Care Hospital

Coverage requirements and clinical standards

Applicable procedure and billing codes

Provider responsibilities, authorization, and documentation

Clinical background and policy purpose

Terms and role definitions