CurrentUnitedHealthcarePolicy BIP142.N

Outpatient and Inpatient Cognitive Habilitation and Rehabilitation Therapy

Defines coverage stance and requirements for cognitive habilitative and rehabilitative therapy in outpatient and inpatient settings for UnitedHealthcare members; includes references to related policies and notes on habilitative service applicability and provider scope. Providers must check member Evidence of Coverage/Schedule of Benefits for eligibility and limits.

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient and Inpatient Cognitive Habilitation and Rehabilitation Therapy

Policy CodePolicy BIP142.N

Change TypeRevised exclusions and administrative reference updates

Effective DateJune 1, 2026

Next Review Date

Key ActionVerify member coverage, confirm medical necessity and scope of practice, and obtain prior authorization for in-home cognitive rehabilitation therapy when required.

SourceLink

POLICY UPDATE CHANGES

Removed instruction to refer to the Medical Policy titled 'Neuropsychological Testing Under the Medical Benefit' from Outpatient Cognitive Habilitation and Rehabilitation Therapy.

For California Large Groups, neuropsychological testing for treatment of functional deficits due to traumatic brain injury or cerebrovascular insult or when provided as part of an authorized autism behavioral health treatment plan is listed as not covered.

Archived previous policy version BIP142.M.

1Policy referenced (BIP142.N)

2026-06-01Effective date

Covered with criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Cognitive Habilitation & Rehabilitation

Outpatient Cognitive Habilitation and Rehabilitation Therapy - Coverage

Covered when services meet the member's plan Evidence of Coverage/Schedule of Benefits (EOC/SOB) and are medically necessary; refer to related Cognitive Rehabilitation and Coma Stimulation and Habilitation and Rehabilitation Therapy policies.

ALL of the following

Service is cognitive habilitative or cognitive rehabilitation therapy provided by a licensed provider acting within scope of licensure (e.g., occupational, physical, speech therapists/pathologists, neuropsychologist, or physician).
Services are medically necessary.
Coverage eligibility, limitations, and exclusions are confirmed in the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB).

ALL of the following

Refer to related medical policies: Cognitive Rehabilitation and Coma Stimulation; Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech).

Inpatient Cognitive Habilitative and Rehabilitation Therapy - Coverage

Covered when the member also meets criteria for inpatient medical rehabilitation services.

ALL of the following

Member meets criteria for inpatient medical rehabilitation services.
Cognitive habilitative or rehabilitative therapy is part of the inpatient rehabilitation plan.

Habilitative Services - Coverage Determination

Habilitative services coverage depends on the member's plan and will be applied under the same terms and conditions as rehabilitative services.

ANY of the following

Habilitative services may be covered or not covered — check member EOC/SOB for specifics.
If requests are for PT, OT, or ST that are habilitative in nature, refer to the Rehabilitation Services (Physical, Occupational, and Speech) or Habilitative Services policies for determination.

Not Covered

These services are explicitly listed as not covered unless otherwise specified and medically necessary under a plan provision.

ANY of the following

Cognitive behavioral therapy (cognitive therapy) unless medically necessary and provided by a provider acting within scope of license or as authorized under California law.
Cognitive habilitative and rehabilitation therapy for any condition other than those listed in the Covered Benefits section.
In-home cognitive rehabilitation therapy unless documented as medically necessary and prior authorized by the member's primary medical group or UnitedHealthcare.
For California Large Groups: Neuropsychological testing for treatment of functional deficits due to a traumatic brain injury or cerebrovascular insult, or when provided as part of an authorized autism behavioral health treatment plan.

Required Provider Actions and Documentation

Prior Authorization

Prior authorization for in-home cognitive rehabilitation

In-home cognitive rehabilitation therapy requires documentation of medical necessity and prior authorization by the member’s primary medical group or UnitedHealthcare.

Documentation Required

Verify member coverage and medical necessity

Confirm member coverage, limitations, and exclusions in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB); ensure requested cognitive habilitative or rehabilitative services are medically necessary and provided by a licensed provider acting within the scope of their licensure.

Coding and Billing Notes

No procedure/diagnosis codes listedmixed

No codes listed

Clinical and Administrative Background

This policy clarifies when cognitive habilitative and rehabilitative therapy is considered covered under UnitedHealthcare benefits and distinguishes determinations of habilitation versus rehabilitation based on the member's Evidence of Coverage/Schedule of Benefits (EOC/SOB). All services must be medically necessary and coverage eligibility, limits, and exclusions are determined by the member's EOC/SOB; if there is a discrepancy between this policy and the member's EOC/SOB, the EOC/SOB governs (see Related Instructions and Covered Benefits).

For outpatient services, refer to the Medical Policies titled Cognitive Rehabilitation and Coma Stimulation and Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech); cognitive habilitative and rehabilitative therapy may be provided by licensed clinicians acting within their scope of licensure (for example, occupational, physical, and speech therapists/pathologists, neuropsychologists, or physicians).

Inpatient cognitive habilitative and rehabilitative therapy is covered when the member also meets the criteria for inpatient medical rehabilitation services and the therapy is part of the inpatient rehabilitation plan.

Habilitative services may or may not be covered depending on the member's plan; habilitative services, when covered, are applied under the same terms and conditions as rehabilitative services in the plan contract. For requests that are habilitative in nature for PT, OT, or ST, refer to the Rehabilitation Services or Habilitative Services policies to determine coverage.

The policy also identifies specific exclusions and administrative notes, including that cognitive behavioral therapy (cognitive therapy) is not covered unless medically necessary and provided by a licensed provider or as authorized under California law; in-home cognitive rehabilitation therapy is not covered unless documented as medically necessary and prior authorized by the member's primary medical group or UnitedHealthcare; and for California Large Groups, certain neuropsychological testing is listed as not covered in specified circumstances. Related benefit and medical policies are noted to guide application across outpatient and inpatient settings.

Definitions

Cognitive habilitation and rehabilitation therapyTherapeutic services aimed at improving cognitive function or helping a member acquire, maintain, or restore cognitive skills; may be provided by licensed therapists, neuropsychologists, or physicians within scope of licensure.

EOC/SOBMember's Evidence of Coverage / Schedule of Benefits — the plan documents that determine coverage eligibility, limits, copayments, coinsurance, deductibles, and exclusions.

Policy Updates

2026-06-01revisedLatest

Removed instruction in Outpatient Covered Benefits to refer to the Medical Policy titled 'Neuropsychological Testing Under the Medical Benefit' and revised the Not Covered list for California Large Groups to add neuropsychological testing exclusions for treatment of functional deficits due to traumatic brain injury or cerebrovascular insult or when part of an authorized autism behavioral health treatment plan.

2026-06-01added

Added a California Large Groups–specific exclusion: neuropsychological testing for treatment of functional deficits due to traumatic brain injury or cerebrovascular insult or when provided as part of an authorized autism behavioral health treatment plan.

2026-06-01

Outpatient and Inpatient Cognitive Habilitation and Rehabilitation Therapy

Coverage Criteria for Cognitive Habilitation & Rehabilitation

Required Provider Actions and Documentation

Coding and Billing Notes

Clinical and Administrative Background

Definitions

Also Read

Policy Updates