Colorado Rocky Mountain Health Plans SNF/IRF/LTACH Coverage Update

Coverage Criteria and Policy Scope

Therapy services medical necessity

Covered when ALL of the following are met

Reasonable and Necessary Therapy Services: Services must be accepted treatments for the member's condition, be of such complexity that only a therapist can safely and effectively perform them (or be provided under the supervision of a therapist), relate directly and specifically to a written plan of care established before treatment begins, and have an amount, frequency, and duration that are reasonable under accepted standards of practice.

Documentation must be legible, relevant, and sufficient to justify the services billed per Medicare Benefit Policy Manual Chapter 15; services that can be safely and effectively performed by unskilled personnel are not considered skilled even if provided or supervised by a therapist.

Inpatient Rehabilitation Facility (IRF) criteria

IRF admission criteria (must demonstrate at admission)

IRF Admission Requirements: Patient requires active and ongoing therapeutic intervention of multiple therapy disciplines (one must be Physical or Occupational Therapy); requires an intensive rehabilitation therapy program; is reasonably expected to actively participate in and benefit significantly from the intensive program; requires physician supervision by a rehabilitation physician with face-to-face visits at least 3 days per week; and requires an intensive, coordinated interdisciplinary approach to rehabilitation.See IRF intensive therapy threshold (generally ≥3 hours/day, ≥5 days/week or ≥15 hours in 7 consecutive days)

Measurable improvement that is of practical value is expected within a prescribed period; full return to prior functioning is not required to meet this standard.

Skilled Nursing Facility (SNF) coverage

SNF coverage stance

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

Refer to Medicare Benefit Policy Manual, Chapter 8 and applicable LCDs/LCAs where present.

Long-Term Acute Care Hospital (LTACH)

LTACH definition and stance

LTACH Definition: Long-Term Acute Care Hospitals (LTACHs) are Medicare-certified short-term acute care hospitals defined for Medicare payment as generally having an average inpatient length of stay greater than 25 days; admissions are for patients requiring extended acute-level care and medical record documentation must support medical necessity.Average inpatient length of stay > 25 days

Medicare does not have a National Coverage Determination (NCD) or LCDs for LTACH medical necessity; reviewers apply clinical judgment using the medical record.

Coverage Highlights

Coverage stance and criteria highlights:

LTACH definition and review: LTACHs are defined for Medicare payment as hospitals with average inpatient length of stay >25 days; medical necessity determinations for LTACH admission rely on documentation in the medical record and reviewer clinical judgment.>25 days

Refer to Medicare Benefit Policy Manual Chapter 1 and CMS guidance for LTACHs.

Private Duty Nursing Services are not covered by Medicare; some Medicare Advantage members may have supplemental benefits — verify the member's Evidence of Coverage before proceeding.

Refer to the UnitedHealthcare Commercial Medical Policy titled 'Private Duty Nursing Services' for coverage guidelines.

Therapy modalities: Certain modalities (e.g., aqua/pool therapy) are covered only when performed as part of an authorized treatment plan with a licensed therapist in attendance; massage is covered only when part of a multi-modality authorized treatment plan with a licensed therapist in attendance.

Compliance with applicable LCDs/LCAs is required where they exist.

Application of Medicare and Internal Coverage Criteria

UnitedHealthcare follows Medicare coverage guidelines when available; when Medicare guidance is absent or allows flexibility, internal coverage criteria are applied

Policy application: Apply Medicare statutes, regulations, NCDs, LCDs, and manuals when applicable. When Medicare guidance is absent or includes explicit flexibility, apply UnitedHealthcare internal coverage criteria developed from clinical evidence and guidelines.

Where Medicare source materials conflict with this policy, the Medicare materials prevail; reviewers exercise clinical judgment based on documentation in the medical record.

Private Duty Nursing Services

Coverage guidance for Private Duty Nursing Services under Medicare and Medicare Advantage:

Private Duty Nursing: Medicare does not have an NCD for Private Duty Nursing Services and LCDs/LCAs do not exist; Medicare does not cover Private Duty Nursing Services, but some UnitedHealthcare Medicare Advantage members may have supplemental benefits — verify the member's Evidence of Coverage prior to authorization.

For coverage guidelines, refer to the UnitedHealthcare Commercial Medical Policy titled 'Private Duty Nursing Services'.

Services related to general good and welfare — such as general exercises to promote overall fitness, activities that provide diversion or general motivation — and services not provided under a valid therapy plan of care or furnished by staff who are not qualified or appropriately supervised are not payable as Therapy Services. These activities do not meet Medicare standards for covered Therapy Services and therefore are excluded from payment.

Medicare does not cover Private Duty Nursing Services; verify the member's Evidence of Coverage for any Medicare Advantage supplemental benefits before pursuing authorization. Additionally, services that are purely general fitness or diversion, and vocational training provided solely for employment purposes, are not covered under outpatient rehabilitation therapy guidance.

Private Duty Nursing Services are not covered by Medicare (see Medicare Benefit Policy Manual, Chapter 1, §20). Some Medicare Advantage members may have supplemental Private Duty Nursing benefits — confirm coverage by reviewing the member's Evidence of Coverage and refer to the UnitedHealthcare Commercial Medical Policy titled "Private Duty Nursing Services" for internal guidance.

Services that can be self-administered or that can be safely and effectively provided by unskilled personnel are not considered skilled therapy services and are not reasonable and necessary even if furnished or supervised by a therapist. Claims may be denied when billed services lack the requirement for a therapist's skill, are performed without appropriate supervision, or are unsupported by documentation demonstrating the need for skilled care.

Massage therapy is considered reasonable and necessary only when it is part of a multi-modality authorized treatment plan appropriate to the patient's diagnosis with a licensed therapist in attendance. Massage provided outside such an authorized plan or without therapist attendance is not considered payable.

When Medicare source materials conflict with this policy, the Medicare materials prevail. This policy is intended to support coverage decisions but does not override statutory or regulatory Medicare requirements; follow Medicare statutes, regulations, NCDs, LCDs, and manuals where applicable.

Applicable Codes and Coding Notes

Applicable therapy and modality 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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Applicable therapy and modality CPT codes (part 2)CPT

97116	Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing).
97124	Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion).
97139	Unlisted therapeutic procedure (specify).

Applicable therapy and functional CPT codesCPT

97140	Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes.
97150	Therapeutic procedure(s), group (2 or more individuals).
97164	Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family..
97168	Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family..
97530	Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
97533	Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes.
97535	Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes.
97537	Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes.
97542	Wheelchair management (e.g., assessment, fitting, training), each 15 minutes.

Work, assistive, orthotic/prosthetic, unlisted, and HCPCS codesmixed

97545	Work hardening/conditioning; initial 2 hours.
97546	Work hardening/conditioning; each additional hour (List separately in addition to code for primary procedure).
97755	Assistive technology assessment (e.g., to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes.
97760	Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes.
97761	Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes.
97799	Unlisted physical medicine/rehabilitation service or procedure.
T1000	Private duty/independent nursing service(s), licensed, up to 15 minutes.

Applicable HCPCS CodesHCPCS

T1000

Private duty/independent nursing service(s), licensed, up to 15 minutes.

IRF intensive therapy threshold

IRF intensive therapy thresholdAt least 3 hours of therapy per day on at least 5 days per week or at least 15 hours within a 7 consecutive day period

LTACH average inpatient stay

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

Not applicable placeholder

Not applicableNot applicable

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

Outpatient Therapy Utilization Management

Outpatient therapy utilization management — For members in states that participate in the Outpatient Therapy Utilization Management Program, providers must follow the Optum Health Solutions Musculoskeletal (MSK) Utilization Management Policy titled Medicare Outpatient Skilled Therapy (PT/OT/ST). Additional Optum Physical Health outpatient rehabilitation therapy program criteria may apply; reference materials are available on the Optum Clinical Policies provider portal.

Follow Optum/Medicare outpatient therapy utilization program where applicable
Additional program-specific criteria may apply via Optum Physical Health Outpatient Rehabilitation Therapy

Prior Authorization

Follow Delegate Prior Authorization Requirements

Follow Delegate Prior Authorization Requirements — When a delegate manages utilization and prior authorization for Medicare Advantage members, providers must adhere to the delegate's prior authorization and utilization management rules in addition to the Health Plan policy.

Where a delegate manages utilization for MA members, providers must follow delegate rules

Facility Admission Criteria

IRF — Admission criteria (top-level node)

IRF Admission: Requires active, ongoing intervention by multiple therapy disciplines (including PT or OT); requires an intensive therapy program; expected to actively participate and benefit significantly; requires rehabilitation physician supervision with face-to-face visits at least 3 days per week; requires coordinated interdisciplinary rehabilitation.Generally at least 3 hours/day on at least 5 days/week (or ≥15 hours in 7 consecutive days)

Measurable improvement that is of practical value is expected within a prescribed period.

SNF — Admission criteria (top-level node)

SNF Admission: Patient requires skilled nursing care and other services in a Medicare-certified SNF bed; coverage factors must be met and documentation must support the skilled level of care.Up to 100 days per benefit period when coverage factors are met

Criteria for Continued Stay Reviews

SNF/IRF/CORF — Continued stay criteria (top-level node)

Continued Skilled Need: Amount, frequency, and duration of services must remain reasonable under accepted standards and documentation must continue to justify billed skilled services in the medical record for continued stay in SNF, IRF, or CORF.

Documentation requirements per Medicare Benefit Policy Manual Chapter 15 §220.3 apply; providers must retain records to support continued need.

LTACH — Continued stay criteria (top-level node)

LTACH continued stay: Continued stay decisions for LTACH patients are determined by reviewer clinical judgment using documentation in the medical record; the LTACH average length-of-stay metric applies to facility classification rather than an individual continued-stay threshold in this document.

Refer to CMS guidance and local contractor policies where applicable.

SNF/LTACH/IRF — Continued stay criteria combined (top-level node)

Discharge Considerations and Criteria

Discharge from IRF or SNF-level care is appropriate when the patient is no longer expected to actively participate in or benefit significantly from the intensive rehabilitation program, or when the patient's care needs can be met safely and effectively by unskilled personnel. Documentation must support the change in level of care and the rationale for discharge.

Discharge from LTACH-level care is appropriate when acute-level needs no longer require LTACH services and documentation supports transition to a lower level of care. Review discharge and claims instructions in the Medicare Benefit Policy Manual, Chapter 1, and applicable CMS LTACH guidance when coding and billing for the transition.

Combined discharge determinations for SNF, LTACH, and IRF should be guided by reviewer clinical judgment using the medical record and applicable Medicare guidance; when Medicare guidance is present, it governs; otherwise apply UnitedHealthcare internal coverage criteria and ensure documentation supports that goals have been met or that skilled services are no longer reasonable and necessary.

Facility Day Limits and Typical Lengths

SNF — Day limits

SNF day limitUp to 100 days per benefit period when coverage factors are met

IRF — Day limits

IRF therapy intensityGenerally at least 3 hours per day on at least 5 days per week (or 15 hours in 7 consecutive days)

LTACH — Day limits

LTACH facility definition>25 days average length of stay (facility-level definition)

Day limits placeholder

Key Definitions

Skilled Therapy Service — definition

Skilled Therapy ServiceA service that requires the skills of a therapist (or supervision by a therapist) because it is complex or the patient’s condition requires professional performance; services that can be safely and effectively performed by unskilled personnel are not skilled even if provided by a therapist.

Comprehensive Outpatient Rehabilitation Facility (CORF)

CORF definitionA facility primarily engaged in providing outpatient rehabilitation to the injured and disabled or to patients recovering from illness.

Private Duty Nursing Services — definition

Private Duty Nursing ServicesServices provided by a private-duty nurse or attendant (RNs, LPNs, or trained attendants) rendered to and restricted to a particular patient; Medicare does not cover these services (refer to Medicare Benefit Policy Manual, Chapter 1, §20).

Background and Policy Context

Skilled therapy services (Physical, Occupational, Speech-Language Pathology) may be necessary to improve, maintain, or prevent deterioration of a member's condition. Whether a service is skilled depends on the need for a therapist's professional skill rather than the diagnosis alone. Covered therapy must be an accepted treatment for the condition, be of such complexity that only a therapist can safely and effectively perform it, be provided under a written plan of care established before treatment begins, and have a reasonable amount, frequency, and duration under accepted standards of practice.

OpenPayer

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