CurrentUnitedHealthcarePolicy CS164PA.D

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

Defines UnitedHealthcare medical policy criteria, documentation, and administrative requirements for habilitation, rehabilitation, and maintenance therapy (occupational, physical, speech) for members in Pennsylvania, referencing InterQual LOC: Outpatient Rehabilitation & Chiropractic for medical necessity determination.

Policy Summary

PayerUnitedHealthcare

PolicyHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Pennsylvania Only)

Policy CodePolicy CS164PA.D

Change TypeMaterial updates to coverage rationale and speech/language considerations; clinical evidence added

Effective DateNov 1, 2025

Next Review Date

Key ActionInclude required evaluation and plan of care elements (medical history, ICD-10 diagnosis, baseline assessments or alternatives, measurable goals, frequency/duration) and maintain referrals on file to support authorization.

SourceLink

POLICY UPDATE CHANGES

Coverage Rationale: Added language that services must not be duplicate services concurrently provided by another type of therapy and must provide different treatment goals, plans, and therapeutic modalities.

Speech and Language Considerations: Added and relocated detailed bilingual/limited English proficiency requirements and dyslexia testing requirements.

Clinical Evidence section added to policy.

Related Policies: Updated reference link to Cognitive Rehabilitation and Coma Stimulation (for Pennsylvania Only); removed reference to Applied Behavior Analysis for Autism Spectrum Disorders.

Corrected typographical errors.

1State-specific policy (Pennsylvania)

External medical necessity tool referenced

6 monthsTypical maximum authorization period

Coverage Summary

Scope: This UnitedHealthcare medical policy (CS164PA.D) defines criteria, documentation, and administrative requirements for habilitation, rehabilitative, and maintenance therapy (occupational, physical, and speech) for members in Pennsylvania only, and references InterQual® LOC: Outpatient Rehabilitation & Chiropractic for medical necessity determinations.

Policy metadata

policy_numberCS164PA.D

subjectHabilitation and Rehabilitation Therapy - Pennsylvania

effective_date2025-11-01

last_review2026-03-01

has_material_changetrue

coverage_stancemixed

Medical Necessity Criteria

Coding

Referenced CPT / HCPCS Codes (provided for reference)mixed

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.

1–10 of 55

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Provider Actions & Prior Authorization

Documentation Required

Referral required prior to initial evaluation

Obtain and have on file a referral from a PCP (MD, DO, PA, NP) or appropriate specialist prior to completion of the initial therapy evaluation unless the state exempts this requirement.

Documentation Required

Evaluation and POC content requirements

Initial evaluation and plan of care must include: a statement of the individual's medical history; a clear diagnosis with the appropriate ICD‑10 code; baseline objective measurements or standardized assessment scores (or documented task‑analysis alternatives if standardized tests cannot be completed); a reasonable prognosis describing potential for meaningful progress; and short‑ and long‑term, functional, measurable, attainable, time‑based goals plus the prescribed treatment frequency, duration, and anticipated session length.

Background & Evidence

This policy distinguishes between three service types: Habilitation services (help a person keep, learn, or improve skills for daily living), Rehabilitative services (improve, adapt, or restore function lost or impaired due to illness/injury/congenital condition), and Maintenance therapy (services to prevent deterioration or maintain function when further clinical improvement is not reasonably expected).

The policy supplements InterQual clinical criteria with Pennsylvania-specific documentation and administrative requirements (including referral, evaluation, plan of care, re-evaluation, treatment note, group therapy, and feeding/swallowing documentation standards) to support medical necessity determinations.

Key definitions from the policy: Habilitation services – services that help a person keep, learn, or improve skills and functioning for daily living; Rehabilitative services – services intended to improve, adapt, or restore impaired or lost functions; Maintenance therapy – services aimed at preventing decline or maintaining function when further improvement is not reasonably expected.

Erikson et al. (2021): Studied 80 second-grade children (40 bilingual Spanish-English paired with monolingual peers) assessing English phonologic differences; found phonological differences persist in school-age bilingual children and may affect learning success; limitations include posthoc analysis and uncertain clinical utility.

Fabiano-Smith et al. (2018): Evaluated diagnostic accuracy of phonological measures (e.g., PCC-R, EML sound accuracy) in bilingual preschool/kindergarten children and found bilingual children often perform like monolingual peers, but misdiagnosis risk remains when standardized articulation tests are used and measures may need adaptation for bilingual children.

Fabiano-Smith & Goldstein (2010): Studied phonological acquisition in typically developing bilingual Spanish-English children (ages 3-4) and found bilingual children maintain separation between phonological systems and demonstrate consonant accuracy within the normal range for monolingual age-matched peers; small sample size limits generalizability.

Revision History

2025-11-01revised (material)

Coverage Rationale language relocated from Benefit Considerations into Coverage Rationale: added that services must not be duplicate services concurrently provided by another type of therapy and must provide different treatment goals, plans, and therapeutic modalities.

2025-11-01revised (material)

Speech and Language Considerations language relocated from Benefit Considerations and clarified: added bilingual/limited English proficiency requirements (culturally and linguistically adapted norm-referenced testing in all languages exposed to the child; deficits must be present in language of highest proficiency; delivery in language of highest receptive proficiency) and dyslexia testing requirements (test results substantiating receptive or expressive language delay must be included with goals).

2025-11-01

Policy Summary

PayerUnitedHealthcare

PolicyHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Pennsylvania Only)

Policy CodePolicy CS164PA.D

Change TypeMaterial updates to coverage rationale and speech/language considerations; clinical evidence added

Effective DateNov 1, 2025

Next Review Date

SourceLink

On This Page

Documentation Required

Re-evaluation timing and content

Re‑evaluations must be completed at least once every six months (or more frequently per state rules) and include date of last evaluation, visits authorized/attended, compliance with home program, objective description of current deficits and severity, demonstration of progress toward each goal using consistent methods, updated prescribed modalities and frequency/duration, a brief prognosis with discharge criteria, and an updated individualized POC/progress summary that is not older than 90 days; if goals remain unmet, document barriers or rationale for modification.

Documentation Required

Treatment session note requirements

Every treatment session note must document: date of treatment; specific treatments provided that match the CPT code(s) billed; accurate length of the session; the individual's response to treatment; skilled ongoing reassessment of progress toward goals; objective, measurable progress using consistent methods; any problems or changes to the POC; individual or caregiver involvement/feedback about home program activities; and the treating provider's signature and date.

Prior Authorization

Authorization period

UnitedHealthcare may authorize therapy services based on clinical review for up to six months when appropriate. Requests for authorization should include the required evaluation, plan of care, and supporting documentation described in this policy to facilitate approval.

Documentation Required

Speech therapy for limited English proficiency

For individuals with limited English proficiency or bilingual exposure, provide culturally and linguistically adapted norm‑referenced testing in all languages the child is exposed to and document that speech/language deficits are present in the language of highest proficiency. Services must be delivered in the language of the individual's highest receptive proficiency. For individuals with dyslexia, include test results substantiating receptive or expressive language delay and goals addressing the corresponding language deficits.

Gildersleeve-Neumann et al. (2008): Compared speech acquisition in 3–4-year-old bilingual and monolingual preschoolers and reported transfer effects and language-specific error patterns in bilingual development that are typical rather than indicative of disorder; differences related to English exposure were observed but overall phonetic inventories and development were similar across groups.

added (non-material)

Clinical Evidence section added to policy (supporting studies and references on bilingual speech/language research included).

2026-03-01revised (non-material)Latest

Administrative update to related policy links: Updated reference link to Cognitive Rehabilitation and Coma Stimulation (for Pennsylvania Only) and removed reference to Applied Behavior Analysis for Autism Spectrum Disorders.

2025-11-12clarified (non-material)

Corrected typographical errors.

2025-11-01clarified (non-material)

Corrected typographical errors noted on policy effective date.