Habilitative Therapy Services (Physical, Occupational, and Speech Therapy) for Individuals Diagnosed with Intellectual Disability/Developmental Delay/Autistic Disorder/Other Developmental Disorder
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Policy governing prior authorization, coverage criteria, and procedural requirements for habilitative physical, occupational, and speech therapy for individuals whose primary diagnosis is intellectual disability, developmental delay, autism, or other developmental disorder for HUSKY Health (Connecticut Medicaid) providers.
No material clinical or coverage changes in this revision.
Coverage Criteria for Habilitative Therapy
Initial Authorization
Covered when ALL of the following are met for initial authorization
Intensive Services
Intensive services (frequency >= 3x/week) may be considered medically necessary when ONE of the short-term conditions AND tolerance are met
If approved, authorization will be given for up to 12 weeks.
Reauthorization
Covered when ALL of the following are met for reauthorization
Physical, occupational, and speech therapies, and audiology services are not covered for individuals 21 years of age and older when provided in an independent setting. Members age 21 and over must receive these services in a clinic setting. This limitation applies to therapy providers and therapy groups; physicians and physician groups are exempt from this setting-based exclusion.
The policy defines physical therapy as diagnostic and treatment services to assess and address an individual's level of functioning (for example, strength, balance, endurance, and range of motion) and to provide therapeutic exercises and modalities (heat, cold, water, electricity) to prevent, restore, or alleviate lost or impaired physical function. The term does not include the use of cauterization or the use of Roentgen rays or radium for diagnostic or therapeutic purposes.
Services that do not meet Connecticut's statutory definition of medical necessity are not covered. Medical necessity requires that services be consistent with accepted standards of medical practice, clinically appropriate in type, frequency, timing, site, extent, and duration, not primarily for convenience, not more costly than an effective alternative, and based on an individualized assessment of the member's condition. If a requested therapy is not clinically appropriate in its type, frequency, or duration, or is primarily for convenience or more costly than equivalent alternatives, it is considered not medically necessary and therefore not covered.
Authorization decisions are made based on medical necessity at the time the authorization is issued and are not a guarantee of payment; coverage determinations rely on the individualized assessment described in the Connecticut definition of medical necessity.
Coding and Frequency Thresholds
| 0421 | Physical Therapy Revenue Center Code |
| 0423 | Physical Therapy Revenue Center Code |
| 0424 | Physical Therapy Revenue Center Code |
| 0431 | Occupational Therapy Revenue Center Code |
| 0433 | Occupational Therapy Revenue Center Code |
| 0434 | Occupational Therapy Revenue Center Code |
| 0441 | Speech Therapy Revenue Center Code |
| 0443 | Speech Therapy Revenue Center Code |
| 0444 | Speech Therapy Revenue Center Code |
| 97010-97530 | Physician Therapy Initial CPT range |
| 97533-97546 | Physician Therapy CPT range |
Provider Requirements, Prior Authorization, and Documentation
Prior authorization required via web portal
Prior authorization is required per the HUSKY Benefit Grids and must be requested via the web portal; authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment.
- Request must be submitted via the web portal and list the referring physician/APRN/PA on the authorization request.
Prior Authorization is required before services start
Prior Authorization is required to approve covered services before delivery or initiation of the plan of care based on CHNCT determination of medical necessity.
No step therapy protocols specified
No step therapy protocols are specified in this policy; however authorization requests must include the evaluation, treatment plan, and supporting documentation described in the Procedure and Clinical Guideline sections.
- Include standardized assessment scores, treatment goals, anticipated frequency/duration, and habilitation potential with the request.
Ensure complete medical necessity documentation
Providers must ensure authorization requests demonstrate medical necessity with clear documentation of skilled interventions, functional impairment, habilitation potential, measurable goals, and a treatment plan — missing elements risk denial.
- Documentation must show services are not duplicative of school-based services or provide rationale why duplicative services are medically necessary (for under‑21 include the required attestation).
- Treatment plan must include diagnosis; standardized assessment results with age comparisons; habilitation potential; skilled interventions; frequency/duration; measurable goals; quantitative outcome measures; and plan for education/home program.
Submit complete authorization packet
Required submission documents: a completed authorization request via the web portal listing the referring physician/APRN/PA; a therapy evaluation including standardized assessment scores and treatment plan; for individuals under 21 an attestation regarding school-based services; and for reauthorization an updated treatment plan plus a minimum of four daily treatment notes.
Use licensed therapy providers
Services must be performed by licensed providers: occupational therapists (OT), occupational therapy assistants under general supervision, physical therapists (PT), and speech-language pathologists who develop written individual programs of treatment and implement plans of care.
Provide school‑service duplication attestation or risk denial
Requests that do not document that services are not duplicative of school-based services — or that fail to justify why duplicative services are medically necessary — may be denied.
- For individuals under 21 the treating therapist must include an attestation stating whether services are not received at school, are not duplicative, or are duplicative but medically necessary with reason.
Do not provide therapy in independent settings for age 21+
Therapy provided in an independent setting is not covered for individuals 21 years of age and older; such services must be provided in a clinic setting (this limitation does not apply to physicians or physician groups).
- Requests for services in prohibited settings for members aged 21+ risk denial; ensure services are billed and delivered in a clinic setting for these individuals.
Definition: Prior Authorization
Prior Authorization is defined as the process for approving covered services prior to delivery or initiation of the plan of care based on a CHNCT determination of medical necessity.
Background and Scope
Habilitative therapy services are intended to help individuals with intellectual disability, developmental delay, autistic disorder, or other developmental disorders to learn, keep, or improve skills and function for daily living that have not developed or are at risk of being lost because of the diagnosis. Coverage is determined by assessing the individual’s unique clinical needs against Connecticut’s definition of medical necessity.
Key Definitions
Policy Revision History
Policy approved by the Department of Social Services (DSS).
Approved by the CHNCT Clinical Quality Subcommittee.
Approved at the CHNCT Medical Reviewer meeting.
Original publication of the habilitative therapy services policy (effective for prior authorization requests on or after 2026-01-01).
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