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ModifiedSelectHealthPolicy 443

Acute Inpatient Rehabilitation

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This policy governs coverage criteria and requirements for acute inpatient rehabilitation (IRF) services for SelectHealth members (Commercial, Medicare, and Community Care/CHIP), detailing qualifying conditions, admission criteria, and program expectations for adult and pediatric patients.

Policy Summary

PayerSelectHealth

PolicyAcute Inpatient Rehabilitation

Policy CodePolicy 443

Change TypeCoverage clarification & criteria updates

Effective DateJun 28, 2023

Last ReviewFeb 11, 2026

Next Review DateN/A

Key ActionVerify member benefits and obtain prior authorization where required; ensure documentation meets all admission and procedure-specific criteria before submission.

SourceLink

POLICY UPDATE CHANGES

Revised to include coverage of this procedure when criteria are met for early lymphedema related only to breast cancer (was previously covered in these circumstances for both breast cancer and melanoma).

Clarified requirements in coverage criteria: 'Select Health covers bioimpedance spectroscopy only for the evaluation or diagnosis of early lymphedema, defined as Stage 0 or 1, related to breast cancer or melanoma.'

For Commercial Plan Policy, changed qualifying condition for this therapy of traumatic brain injury (TBI) to acquired brain injury (ABI), which allows inclusion of non-traumatic brain injuries as well.

Removed previous requirements pertaining to intrathecal baclofen therapy that were already outlined in medical policy #137.

Clarified that test (e.g., trial) dosing requirement does not apply to cancer patients.

Removed previous criterion regarding nerve blocks and replaced with 'Pain interventions are either contraindicated or have failed.'

Updated physical therapy requirement to a minimum of 12 visits within a 6-week period, performed within the previous year (recommendation that at least four visits be in-person).

Coverage Criteria and Medical Necessity

Criteria for coverage: Initial admission

Covered when ALL of the following are met:

Admission Criteria: 1. The patient requires close medical supervision by a physiatrist or other physician qualified by specialized training and experience in inpatient rehabilitation to monitor their medical condition; 2. The patient's medical conditions are sufficiently stable to be reasonably managed in an inpatient rehabilitation facility and allow routine participation in a structured rehabilitative program; 3. The patient requires multidisciplinary care (physical therapy, occupational therapy, speech-language pathology, and psychosocial services) to achieve optimal functional recovery with a minimum of three (3) hours active participation daily; 4. The patient is physically and cognitively capable and willing to participate in at least 3 hours of an intensive physical rehabilitation program; 5. Clearly written functional goals are defined by a program manager within 5 days of admission, including documentation of discharge planning and demonstration of progression toward goals; 6. A written statement certifies the patient has a high probability of achieving measurable functional improvement from the planned program of care within a maximum of 7–14 days (depending on diagnosis); 7. The patient has a community-based environment and available care providers with a high likelihood of successful reintegration; 8. The patient has been evaluated and accepted by the admitting physician or designee as meeting the above requirements.all must be met

Admission requires ALL listed criteria to be met (AND logic).

Qualifying conditions

Examples of conditions for which patients may qualify (not exhaustive):

Adult qualifying conditions: Central nervous system disorders (stroke, Parkinson's disease, multiple sclerosis, post meningoencephalitis, ALS), traumatic brain injury with appropriate Rancho levels and behavior considerations; spinal cord injury (quadriplegia/paraplegia, Brown-Sequard, post-spinal neurosurgery, transverse myelitis, spinal infectious disease); medical conditions with functional limitation (cardiac surgery/disease, severe lung disease, failed vent weaning, tracheostomy); uncontrolled pain due to neurologic or musculoskeletal etiology meeting prior conservative therapy requirements; complex medical issues including frailty with prolonged ICU stay or post-transplant; musculoskeletal conditions (amputation with comorbidity, femur fracture with complicating condition, major joint replacement with functional limitation); burns with deep partial-thickness or full thickness involving ≥15% body surface area.

Any of these may indicate need for IRF if admission criteria met.

Pediatric qualifying conditions: CNS/TBI (acute disseminated encephalomyelitis, MS, anoxic or traumatic brain injury, CVA, Guillain-Barre, meningitis/encephalitis, neoplasm, post-craniotomy) including Rancho level criteria; burns with inhalation injury or requiring at least minimum assistance plus two listed impairments; medically complex (extended acute hospitalization, failed vent weaning/tracheostomy, malignant disease excluding end-stage, ventilator management); musculoskeletal and trauma (major joint replacement with comorbidity, amputation >1 limb, multiple fractures) as described in pediatric examples.

Pediatric examples provided separately in policy.

Bioimpedance Spectroscopy — Covered Indications

Covered when ALL of the following are met:

BIS coverage for early lymphedema: Bioimpedance spectroscopy (BIS) is covered only for the evaluation or diagnosis of early lymphedema (Stage 0 or Stage I) related to breast cancer.Stage 0 or Stage I

For all other indications BIS is considered experimental/investigational under the commercial plan; billing/coding: covered when criteria met.

Payer-specific applicability

Medicare/Community Care applicability: SelectHealth Medicare follows CMS determinations; SelectHealth Community Care typically aligns with State Medicaid (Utah Medicaid) and InterQual criteria. If CMS has not adopted a determination and InterQual criteria are not available, SelectHealth Commercial policy applies.

Payer-specific applicability statement.

Covered Indications for BIS

Covered when ALL of the following are met:

Primary coverage conditions for BIS: 1) Patient is at risk for or has symptoms/signs concerning for early lymphedema (Stage 0 or Stage I); 2) Clinical context relates to breast cancer (policy revision limits coverage to breast cancer–related early lymphedema); 3) Documentation supports use of BIS for evaluation/diagnosis as part of screening or early detection per NCCN guidance.Stage 0 or 1

Derived from NCCN endorsement and revision history; covered when billing/coding indicates criteria met.

Evidence-based context (informational)

Clinical summary supporting use (no formal criteria provided in this section):

Evidence summary: Spinal manipulation and chiropractic care have an expanding evidence base demonstrating benefit and safety for low back pain, neck pain, headaches, and some discogenic conditions; multidisciplinary care (manipulation plus exercise/usual care) often yields better outcomes than manipulation alone. Recent guideline endorsements (eg, ACP 2017) and systematic reviews support use as part of conservative care pathways and may reduce downstream imaging, surgeries, and opioid use.

Informational summary of referenced evidence and guideline support; no coverage criteria specified.

Coverage for Cognitive Rehabilitation

Covered when part of a comprehensive rehabilitation program for the listed diagnoses

Eligibility: Cognitive rehabilitation is covered when provided as part of a comprehensive physical, occupational, and/or speech rehabilitation program for patients with cerebrovascular accident (CVA/stroke) or acquired brain injury (ABI).

Coma stimulation is explicitly not covered (investigational).

Criteria for Coverage (microprocessor knee prostheses)

Select Health covers microprocessor-controlled knee prostheses when any of the following criteria are met:

K-Level 3 or 4: Patient is a K-Level 3 or K-Level 4 (community ambulator with variable cadence or higher).K-Level 3 or 4

Direct coverage for higher functional classification levels.

K-Level 2 with trial: Patient is a K-Level 2 with a documented trial of a standard prosthetic and demonstrated potential to achieve K-Level 3.K-Level 2 with trial and potential

Requires prior trial of a standard prosthetic before coverage consideration.

CIMT Coverage Criteria

Commercial plan/CHIP coverage statement for CIMT

CIMT medical necessity criteria (overview): Constraint-induced movement therapy (CIMT) is considered medically necessary for treatment of upper limb hemiparesis in post-stroke patients who meet the specific clinical criteria below.

Commercial and CHIP policy statement.

Coverage Criteria for CIMT (Commercial and CHIP)

SelectHealth covers CIMT when ALL of the following are met:

CIMT coverage criteria: 1) Patient is a post-stroke patient with upper limb hemiparesis; 2) Patient has at least 10 degrees of active wrist and finger extension; 3) Patient has no sensory deficits; 4) Patient has no cognitive deficits.>=10 degrees

Numeric threshold and exclusions (sensory/cognitive deficits) specified in policy.

Experimental/Investigational Indications (CIMT)

SelectHealth considers CIMT experimental/investigational for ALL OTHER indications, including but not limited to:

Investigational indications: Treatment of traumatic brain injury (TBI); treatment of cerebral palsy; and other non–post-stroke indications. Claims for these indications are considered investigational and are not covered.

Policy explicitly excludes non–post-stroke uses of CIMT.

RFA (rhizotomy) — initial coverage

Covered when ALL of the following are met

RFA coverage prerequisites: Non-pulsed thermal radiofrequency ablation (RFA) of sacral (S1 only), cervical, and lumbar facet joints is covered when: (1) MBBs are covered per policy A(14); AND (2) the diagnosis of facet joint pain has been confirmed by a controlled, two-step diagnostic medial branch block (MBB) performed under fluoroscopic guidance without analgesics and each block produced ≥80% pain reduction consistent with anesthetic duration; AND (3) other conditions in section A(14) are met (including documentation and procedural guidance).

All listed prerequisites must be met before RFA coverage.

Therapeutic facet injections — continuation criteria

Subsequent therapeutic steroid facet joint injections performed at the same level(s)/side are covered when ALL the following are met

Subsequent therapeutic injections: a) The medical record documents that prior therapeutic steroid facet joint injections resulted in ≥50% reduction of facet-related pain OR improvement in ability to perform previously painful movements/ADLs; b) The benefit lasted at least 3 months; c) Documentation explains why radiofrequency neurotomy is not a treatment option (e.g., spinal pseudarthrosis or implanted electrical device).

A maximum of 4 therapeutic steroid facet joint injections is allowed per rolling 12 months.

Therapeutic facet injections — initial criteria (chronic and acute)

Covered when ALL the following are met

First therapeutic steroid injection (chronic pain): a) Base criteria in section A (1–4) have been met; b) The patient has had two diagnostic anesthetic facet joint injections (without steroids) at the same level(s)/side; c) Medical record confirms each diagnostic injection provided ≥80% pain relief consistent with the duration of the anesthetic agent; d) Documentation explains why RFA is not a treatment option when applicable.

Medial branch blocks that include corticosteroids are considered therapeutic, not diagnostic.

Acute severe facet-mediated pain: For severe acute facet-mediated pain provoked by facet maneuvers, a single-level therapeutic facet intervention is covered; up to two injections are allowed within a 3-month period without requiring two diagnostic blocks.

Acute pain exception described in policy.

Medial Branch Blocks (MBB)

Covered when ALL of the following are met

MBB coverage and repeat: SelectHealth may cover up to two medial branch blocks when the base criteria in section A (1–4) are met; a second MBB is covered when the previous MBB achieved ≥80% pain reduction consistent with the anesthetic duration and other section A criteria are satisfied. Medial branch blocks that include corticosteroids are therapeutic, not diagnostic.

Diagnostic MBB response threshold defined in policy.

Repeat RFA

Repeat RFA is covered when ALL the following are met

Repeat RFA criteria: i) Patient experienced ≥50% reduction in facet-related pain from the previous RFA OR ii) patient experienced ≥50% improvement in ability to perform previously painful movements/ADLs after previous RFA; AND iii) at least 6 months have elapsed since the previous RFA.

Repeat RFA procedures do not require further physical therapy or chiropractic therapy.

Facet cyst aspiration/rupture

Covered when ALL the following are met

Facet cyst aspiration/rupture: a) Advanced diagnostic imaging (MRI/CT/myelogram) confirms compression or displacement of the corresponding nerve root by a facet joint synovial cyst; b) Clinical and physical symptoms related to the synovial facet cyst are documented.

Cyst aspiration/rupture may be repeated once if prior procedure produced ≥50% pain reduction lasting at least 3 months.

Not covered — Experimental/Investigational

Coverage determination for Commercial Plan and CHIP:

Commercial/CHIP exclusion: SelectHealth does NOT cover lysis of epidural adhesions (percutaneous or endoscopic) for any indication because the technology is considered experimental/investigational due to limited and weak evidence and lack of medical consensus.

Policy explicitly states noncoverage for Commercial Plan and CHIP.

Evidence summary / coverage context

Coverage stance and evidence summary

Coverage context: Although multiple systematic reviews suggest epidural adhesiolysis can be effective, the literature is limited by single-institution studies, small sample sizes, lack of long-term outcomes, and absence of trials comparing to other surgical procedures; these limitations inform SelectHealth's noncoverage stance for Commercial and CHIP plans.

Evidence summary provides context for coverage decision.

Not Covered — Functional Anaesthetic Discography

Coverage determinations in these sections:

Functional anaesthetic discography coverage: SelectHealth Commercial Plan and CHIP do NOT cover functional anesthetic discography; it is classified as experimental/investigational.

Policy states noncoverage for this procedure.

Not Covered — Functional Electrical Stimulation / NMES

FES/NMES coverage stance: SelectHealth Commercial Plan and CHIP do NOT cover functional electrical stimulation (FES) or neuromuscular electrical stimulation (NMES); these are considered experimental/investigational for the indicated uses.

Clinical descriptions provided but declared not covered.

Not Covered / Investigational

Not covered as investigational: FES/NMES for the indicated uses is classified as Investigational/Experimental/Unproven and is listed as Not covered in billing/coding information.

Billing/coding section indicates investigational status.

Commercial plan coverage criteria

Covered when ALL of the following are met

Primary indication: Member has either chronic anorectal pain associated with radiation proctitis OR chronic coccydynia.

Primary covered indications for ganglion impar block.

Conservative therapy failure: Member must have failed at least 3 months of conservative therapy (eg, NSAIDs, local analgesics, modified wedge-shaped/coccygeal cushions).>=3 months

Documentation of conservative therapy failure required prior to coverage.

Procedure frequency limit: No more than four ganglion impar blocks are covered per rolling 12 months.<=4 per 12 months

Policy limit applies and must be documented.

Covered indications and criteria (external and implantable infusion pumps)

SelectHealth covers external and implantable infusion pumps when the following grouped conditions are met for the indicated use:

External pump coverage examples: External infusion pumps are covered for specific indications such as administration of deferoxamine for acute iron poisoning and institutional use of external pumps for heparin in thromboembolic disease; other external pump uses (eg, chemotherapy, morphine intractable pain) are covered when the overall therapy plan including the pump is verified as appropriate and medically necessary.

External pumps coverage limited to listed examples and requires verification of medical necessity.

Implantable pumps — chemotherapy: Implantable infusion pumps are covered when appropriate for continuous administration of chemotherapy drugs (eg, intrahepatic chemotherapy for liver metastases from colorectal cancer) and when FDA labeling supports the drug/pump use.

Specific oncologic indications described in policy.

Implantable pumps — chronic pain criteria: For management of chronic non-malignant pain, ALL of the following must be met: a) treatment decisions managed by a certified physician pain specialist; b) more conservative methods have failed, including (1) OTC drugs (eg, NSAIDs), (2) physical therapy: minimum of 12 visits within a 6-week period performed within the previous year (recommend at least 4 in-person), (3) psychological/behavioral therapies, (4) pain interventions are either contraindicated or have failed; c) further surgical intervention is not indicated or pump therapy has a 50%–75% or better likelihood of success; d) pain is not completely or specifically neuropathic in origin; e) no contraindications to surgery (eg, sepsis, coagulopathy); f) psychological clearance obtained (not necessary for malignant pain patients); g) documented long-term follow-up plan managed by a certified pain specialist; h) successful test (trial) dosing (does not apply to cancer patients).

For Medicare members, coverage determinations are made by the Centers for Medicare & Medicaid Services (CMS). If CMS has not adopted a coverage determination for a service and InterQual criteria are not available, the SelectHealth Commercial policy will be applied to the Medicare claim. Providers should verify the current CMS position and the member's benefit at the time of request because coverage is dependent on the member's benefit plan and any applicable CMS guidance.

SelectHealth classifies bioimpedance spectroscopy (BIS) as experimental/investigational for all indications except the evaluation or diagnosis of early lymphedema (Stage 0 or I) related to breast cancer. Because evidence of clinical utility is lacking for other uses, BIS outside this specific indication does not meet plan criteria for coverage under the Commercial/CHIP policy.

Policy revisions narrowed BIS coverage. The policy was previously written to allow BIS for early lymphedema related to breast cancer or melanoma; the most recent revision clarifies that coverage is limited to early lymphedema (Stage 0 or 1) related to breast cancer only. Providers must document that the clinical context is breast cancer–related and that the patient meets the defined early lymphedema stage criteria to qualify for coverage.

The lists of CPT, HCPCS and diagnosis codes included in this policy are provided for informational purposes only. Inclusion or exclusion of a code in the policy does not guarantee member coverage or provider reimbursement; benefits are determined by the member's individual contract in effect at the time services are rendered. Providers should verify benefit eligibility and prior authorization requirements with the member's plan before furnishing services.

SelectHealth does not cover coma stimulation (HCPCS S9056). The policy identifies this intervention as investigational/unproven for the indicated use, and requests for this service will be denied under the Commercial/CHIP policy.

The presence or absence of a procedure, diagnosis, or device code in this policy is not by itself determinative of coverage or reimbursement. Inclusion/exclusion of codes does not guarantee member coverage or provider payment; coverage decisions depend on the member's specific benefit plan and applicable prior authorization rules.

Billing Codes and Coding Guidance

CPT/HCPCS codes listedmixed

No codes listed

Covered CPT CodesCPTCovered

93702

Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s)

Applicable ICD-10 CodesICD-10

C50.812	Malignant neoplasm of overlapping sites of left female breast
C50.819	Malignant neoplasm of overlapping sites of unspecified female breast
C50.821	Malignant neoplasm of overlapping sites of right male breast
C50.822	Malignant neoplasm of overlapping sites of left male breast
C50.829	Malignant neoplasm of overlapping sites of unspecified male breast
C50.911	Malignant neoplasm of unspecified site of right female breast
C50.912	Malignant neoplasm of unspecified site of left female breast
C50.919	Malignant neoplasm of unspecified site of unspecified female breast
C50.921	Malignant neoplasm of unspecified site of right male breast
C50.922	Malignant neoplasm of unspecified site of left male breast

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Procedures and modalities (informational)CPT

97012	Application of a modality to 1 or more areas; traction, mechanical
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended), each 15 minutes
97024	Application of a modality to 1 or more areas; diathermy (eg, microwave)
97028	Application of a modality to 1 or more areas; ultraviolet
97032	Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
97033	Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
97035	Application of a modality to 1 or more areas: ultrasound, each 15 minutes
97110	Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises
97112	Neuromuscular reeducation (includes gait training)
97116

Therapies, CMT, and E&M codes (informational)CPT

97124	Therapeutic procedure; massage, each 15 minutes
97140	Manual therapy techniques (e.g., mobilization/manipulation), each 15 minutes
97530	Therapeutic activities, direct (one-to-one) patient contact, each 15 minutes
98940	Chiropractic manipulative treatment (CMT); spinal one to two regions
98941	CMT; spinal three to four regions
98942	CMT; spinal five regions
98943	CMT; extraspinal, one or more regions
99202	Office/outpatient visit for new patient, expanded problem-focused history/exam; straightforward MDM
99203	Office/outpatient visit for new patient, detailed history/exam; low complexity MDM
99204	Office/outpatient visit for new patient, comprehensive history/exam; moderate complexity MDM

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Operative/other manipulation codesCPT

22505

Manipulation of spine requiring anesthesia, any region

Manipulation (CMT) CodesCPT

98940	Chiropractic manipulative treatment (CMT); spinal, one or two regions
98941	CMT; spinal, three to four regions
98942	CMT; spinal, five regions
98943	CMT; extraspinal, one or more regions

Covered CPT CodesCPTCovered

96125

Standardized cognitive performance testing per hour of a qualified health care professional's time, including administering tests, interpreting results, and preparing report

Covered CPT Codes (continued)CPTCovered

91729	Therapeutic interventions that focus on cognitive function, direct (one-on-one) patient contact; initial 15 minutes
97130	Therapeutic interventions that focus on cognitive function, each additional 15 minutes

Not covered HCPCSHCPCSNot Covered

S9056

Coma stimulation per diem

CPT CodesCPT

No CPT codes identified

No specific CPT codes were identified in this section.

HCPCS Codes (prosthetic features and additions)HCPCSCovered

L5856	Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type
L5857	Addition to lower extremity prosthesis, endoskeletal knee-shin system; swing phase only, includes electronic sensor(s), any type
L5858	Addition to lower extremity prosthesis, endoskeletal knee-shin system; stance phase only, includes electronic sensor(s), any type
K1014	Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control
K1022	Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type
L2006	Knee ankle foot device, any material, single or double upright, swing and stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type activation, with or without ankle joint(s), custom fabricated
L5859	Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)

CPT CODESCPT

97799	Unlisted physical medicine/rehabilitation service or procedure
92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508	Group, 2 or more individuals
97110	Therapeutic procedure; therapeutic exercises, each 15 minutes
97112	Neuromuscular reeducation, each 15 minutes
97140	Manual therapy techniques, one or more regions, each 15 minutes
97530	Therapeutic activities, direct (one-to-one), each 15 minutes

HCPCS CODESHCPCS

G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes
S9131	Physical therapy; in home, per diem

Covered procedure codesCPTCovered

64490	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint with image guidance; cervical or thoracic; single level
64491	Second level (addition) cervical or thoracic
64492	Third and any additional level(s) cervical or thoracic (addition)
64493	Injection(s) ... lumbar or sacral; single level
64494	Second level lumbar or sacral (addition)
64495	Third and any additional level(s) lumbar or sacral (addition)
64633	Destruction by neurolytic agent, paravertebral facet joint nerve(s) with imaging guidance; cervical or thoracic, single facet joint
64634	Destruction by neurolytic agent ... cervical or thoracic, each additional facet joint
64635	Destruction by neurolytic agent ... lumbar or sacral, single facet joint
64636	Destruction by neurolytic agent ... lumbar or sacral, each additional facet joint

1–10 of 16

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HCPCSHCPCS

No codes listed

CPT CodesCPT

62263	Percutaneous lysis of epidural adhesions using solution injection or mechanical means; multiple adhesiolysis sessions; 2 or more days
62264	Percutaneous lysis of epidural adhesions; 1 day

HCPCS CodesHCPCS

J7131

Hypertonic saline solution, 1 ml

CPT CODESCPT

62290	Injection procedure for discography, each level; lumbar
62291	Injection procedure for discography, each level; cervical or thoracic
72285	Discography, cervical or thoracic, radiological supervision and interpretation
72295	Discography, lumbar, radiological supervision and interpretation

HCPCS CODESHCPCS

No codes listed

CPT Codes (FES/NMES section)CPT

No specific CPT codes identified

The document states no specific CPT codes identified for FES/NMES.

HCPCS Codes (FES/NMES)HCPCS

E0764

Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, entire system

CPT CodesCPT

64999

Unlisted procedure, nervous system

CPT Codes (implantation/refill/device groups)CPT

36260	Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir.
36261	Implantation; non-programmable pump.
36262	Implantation; programmable pump, including preparation of pump, with or without programming.
62324	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus... interlaminar epidural or.
62325	62324 with imaging guidance (ie, fluoroscopy or CT).
62326	Injection(s)... lumbar or sacral (caudal); without imaging guidance.
62327	62326 with imaging guidance (ie, fluoroscopy or CT).
62350	Implantation, revision or repositioning of tunneled intrathecal or epidural catheter; without laminectomy.
62351	62350 with laminectomy.
62355	Removal of previously implanted intrathecal or epidural catheter.

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Additional CPT/Service CodesCPT

77003	Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures.
95990	Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal or brain, includes electronic analysis of pump, when performed.
95991	95990 requiring skill of a physician or other qualified health care professional.
96521	Refilling and maintenance of portable pump.
96522	Refilling and maintenance of implantable pump or reservoir for systemic drug delivery.
96523	Irrigation of implanted venous access device for drug delivery systems.

HCPCS Codes (implantation/refill/device supplies)HCPCS

A4220	Refill kit for implantable infusion pump
C1772	Infusion pump, programmable (implantable)
E0782	Infusion pump, implantable, non-programmable (includes all components).
E0783	Infusion pump, implantable, programmable (includes all components).
E0785	Implantable intraspinal catheter used with implantable infusion pump, replacement.
E0786	Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter).

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

Coverage contingent on meeting admission criteria

Coverage is contingent on meeting all specified admission criteria and applicable benefit coverage at the time of request. SelectHealth applies coverage based on the member's individual benefit plan in effect at the time of service. Failure to meet all required admission criteria may result in denial of acute inpatient rehabilitation coverage.

Coverage is applied based on the member's benefit at the time of the request.
Admission requires physician evaluation and acceptance (see Criteria for coverage).
Document multidisciplinary needs, functional goals within 5 days, and physician certification of measurable improvement potential.

Note

Medicare coverage determination

For Medicare members, coverage determinations are made by CMS. If CMS has not adopted a coverage determination and InterQual criteria are not available, the SelectHealth commercial policy applies. Providers should refer to the CMS coverage database for the most current Medicare determinations.

Key Clinical Thresholds and Program Parameters

Therapy intensity — IRF minimums

Therapy intensity (daily)Minimum 3 hours active participation daily

Therapy intensity (weekly)Minimum 15 hours per week (minimum 3 hours/day x 5 days)

Interdisciplinary staffingSufficient staff to provide therapy and meet rehab nursing needs (PT/OT/SLP and others) to support ≥3 hours/day

Unintentional weight loss threshold

Unintentional weight loss≥ 10 lbs in the previous year

Relative weight lossOr ≥ 5% of the previous year's body weight

Context

Background, Definitions, and Clinical Context

Inpatient rehabilitation facilities (IRFs) are hospital-licensed units that provide intensive, multidisciplinary rehabilitation services with 24/7 physician and nursing availability and specialized therapy staff. Typical IRF expectations include a multidisciplinary team, documented functional goals, and patient capability and willingness to participate in intensive therapy (commonly a minimum of 3 hours per day of active therapy). Clinical admission requires physician evaluation and documentation that the patient meets the IRF admission criteria.

IRF definition

IRF (Inpatient Rehabilitation Facility)A licensed hospital unit providing intensive rehabilitation services with 24/7 availability of physicians and nurses experienced in medical rehabilitation

Therapy staffingSufficient therapists (PT/OT/SLP) and others to provide at least 3 hours/day per patient

Multidisciplinary teamIncludes rehab physicians, nurses, therapists, social workers, psychologists, and discharge planning

Fried frailty score

Policy Revision History and Material Changes

2026-02-19revised

Clarified and updated implantable infusion pump chronic pain criteria to require a minimum of 12 physical therapy visits within a 6-week period (performed within the previous year, with recommendation that ≥4 be in-person) and revised conservative therapy wording to state 'Pain interventions are either contraindicated or have failed'.

2025-11-01revised

Removed a prior specific requirement about nerve blocks and replaced it with the broader statement that 'Pain interventions are either contraindicated or have failed' in implantable pump criteria; updated conservative therapy requirements.

2025-06-20

Policy Summary

PayerSelectHealth

PolicyAcute Inpatient Rehabilitation

Policy CodePolicy 443

Change TypeCoverage clarification & criteria updates

Effective DateJun 28, 2023

Last ReviewFeb 11, 2026

Next Review DateN/A

Key ActionVerify member benefits and obtain prior authorization where required; ensure documentation meets all admission and procedure-specific criteria before submission.

SourceLink

On This Page

Prior Authorization

Prior authorization and clinical documentation for BIS

Bioimpedance spectroscopy (BIS) (CPT 93702) is covered only for the evaluation/diagnosis of early lymphedema (Stage 0 or I) related to breast cancer when policy criteria are met. For all other indications BIS is considered experimental/investigational and not covered.

CPT 93702 covered only for Stage 0 or I lymphedema related to breast cancer.
For other indications 93702 is experimental/investigational and not covered.
Obtain prior authorization when required by the member's benefit plan.

Prior Authorization

Check member coverage / prior authorization

Providers must verify member benefits and prior authorization requirements before delivering services. Coverage, prior authorization, and claim payment are determined by the member's individual benefit plan in effect at the time services are rendered.

Refer to the member's contract/ID card for Customer Service contact information.
Providers may call SelectHealth Provider Relations at (801) 442-3692 with policy questions.
Verify whether prior authorization is required for the requested service under the member's plan.

Denial Risk

Coverage requirements and exclusions

Certain services are covered only as part of a comprehensive rehabilitative program or when specified clinical criteria are met (e.g., cognitive rehabilitation only when part of comprehensive rehab for CVA/ABI). Services lacking sufficient evidence (e.g., coma stimulation, FES/NMES, functional anesthetic discography) are excluded.

Cognitive rehabilitation covered only as part of comprehensive physical/occupational/speech therapy for CVA or ABI.
Coma stimulation is considered investigational and is not covered.
FES/NMES and functional anesthetic discography are investigational and not covered.

Prior Authorization

Benefit-dependent coverage / prior authorization

Coverage of devices and certain procedures is benefit-dependent and may require prior authorization. Examples include microprocessor-controlled knee prostheses (HCPCS L5856-L5859, L2006, K1014, K1022) and implantable infusion pumps (CPT/HCPCS listed in policy) — coverage requires meeting specific clinical criteria and verification of member benefit.

Microprocessor knee criteria require K-Level 3/4 or K-Level 2 with a trial of standard prosthetic and potential for K-Level 3.
Implantable pump coverage requires documented failure of conservative therapies and pain specialist management.
Obtain prior authorization for prosthetic additions and implantable pumps as required by member benefits.

Prior Authorization

Prior authorization for RFA when criteria apply

Prior authorization is implied or required for radiofrequency ablation (RFA) when diagnostic confirmation is necessary. RFA of cervical, lumbar, and sacral (S1) facets is covered only when controlled, two-step diagnostic medial branch blocks (MBBs) with ≥80% pain relief confirm the diagnosis; documentation must explain why RFA is appropriate or why alternatives are not suitable.

Two controlled diagnostic MBBs required with ≥80% pain relief consistent with anesthetic duration prior to RFA.
Repeat RFA covered if prior RFA provided ≥50% pain relief or ≥50% functional improvement and ≥6 months elapsed.
Thoracic facet RFA is excluded (investigational) except for select self-funded groups.

Documentation Required

Verify benefits and prior authorization

Verify member benefits, eligibility, and any required prior authorization with SelectHealth before performing procedures. Benefit verification should be documented in the medical record.

Benefits and eligibility are determined by the member's individual benefit plan at time of service.
Providers should document verification and any authorization numbers in the chart.
Contact Member Services at the number on the member ID card for benefit questions.

Billing Rule

Prior authorization for listed codes

Prior authorization is expected for listed implantation, refill, maintenance, and device supply codes for implantable pumps and prosthetic device additions. Use the policy code lists for information and confirm requirements with benefits.

CPT codes (implantation, revisions, removals) listed in pump policy should be supported by prior authorization when required.
HCPCS codes for devices and supplies (e.g., A4220, C1772, E0782-E0786, L5856-L5859) are informational—coverage depends on benefits.
Prior authorization supports medical necessity for device implantation and follow-up supplies.

Denial Risk

Denial triggers and required documentation

If required clinical or administrative criteria are not met, services may be denied. This includes failure to demonstrate prior conservative therapy where required, lack of required diagnostic confirmation, or omission of essential documentation (e.g., physician admission justification, functional goals, percent pain relief and duration for diagnostic blocks).

Denial risk if documentation does not show failure of required conservative therapy (e.g., ≥3 months for ganglion impar blocks, required PT/OT trials for uncontrolled pain).
Denial risk if diagnostic blocks do not document percent pain relief and duration (e.g., ≥80% for diagnostic facet blocks).
Denial risk if inpatient rehab admission criteria and physician certification are not documented.

Documentation Required

CIMT documentation and denial triggers

Constraint-Induced Movement Therapy (CIMT) coverage requires documentation of at least 10 degrees of active wrist and finger extension and absence of significant sensory or cognitive deficits. Claims may be denied if the patient does not meet these functional requirements or if documentation is inadequate.

Document active wrist/finger extension ≥10 degrees and type of therapy provided.
CIMT is experimental/investigational for indications other than post-stroke upper limb hemiparesis and will be denied for unsupported indications.
Include relevant CPT/HCPCS codes and clinical rationale in the request.

Denial Risk

Investigational/Experimental exclusions — denial risk

Services deemed investigational/experimental (e.g., coma stimulation, thoracic RFA, pulsed radiofrequency, laser, cryodenervation, chemical denervation, FES/NMES, functional anesthetic discography) are excluded and requests will be denied. Providers should not assume coverage for investigational procedures even if codes are listed for informational purposes.

Thoracic facet RFA and related diagnostic blocks are excluded (except select self-funded groups).
Coma stimulation, FES/NMES, and functional anesthetic discography are considered investigational and will be denied.
Inclusion of a code in the policy does not imply coverage — verify member benefits.

Step Therapy

Failure of conservative therapy — documentation requirement

Providers must document attempts and failure of conservative therapies where required (examples: at least 3 months conservative therapy before ganglion impar block; at least 2 outpatient PT/OT trials and 2 trials of pharmacologic/nonpharmacologic treatments for uncontrolled pain prior to inpatient rehab consideration).

For ganglion impar blocks, document ≥3 months of conservative therapy (NSAIDs, local analgesics, cushions, etc.).
For inpatient rehab for uncontrolled pain, document ≥2 outpatient PT/OT trials and ≥2 pharmacologic/nonpharmacologic trials.
For implantable pumps, document failure of specified conservative therapies (PT, psychological therapies, OTC meds).

Denial Risk

Contraindications and investigational uses — documentation

Contraindications and investigational uses (e.g., infection, allergy, body size, interacting medications) for implantable pumps and other devices must be documented. Requests that fall into contraindicated or investigational categories will be denied.

Document absence of contraindications (e.g., sepsis, coagulopathy) and psychological clearance when required.
Pump implantation requires certification by a pain specialist and documentation of trial dosing when applicable.
If the use is investigational or contraindicated, provide clinical justification — otherwise expect denial.

Documentation Required

Required clinical documentation

Required clinical documentation for requests includes: physician admission justification and acceptance, multidisciplinary care plan, clearly written functional goals with progression documentation, percent pain relief and duration for diagnostic/therapeutic injections, evidence of conservative therapy attempts, and device-specific clinical criteria (e.g., K-Level assessment for prosthetics, active ROM for CIMT).

Physician certification of measurable improvement potential within 7–14 days for inpatient rehab.
Document percent pain relief after diagnostic injections (e.g., ≥80% for diagnostic facet blocks) and duration consistent with agent used.
For prosthetics, document K-Level assessment and any trial of standard prosthetic for K-Level 2 candidates.

Note

Verify benefits and contact information

Administrative contacts and benefit verification: Members may contact Customer Service via the phone number on their member ID card for benefit questions. Providers may contact SelectHealth Provider Relations at (801) 442-3692 for policy or coverage inquiries.

Document benefit verification and any authorization numbers in the medical record.
Use member ID card phone number for member-specific benefit questions.
Provider Relations: (801) 442-3692.