Follow Idaho Medicaid clinical criteria and InterQual for prior authorization

Prior authorization and coverage determinations should follow the Idaho Medicaid Provider Handbook clinical criteria for Cognitive Rehabilitation and InterQual LOC: Outpatient Rehabilitation & Chiropractic for number and frequency of visits; coma stimulation is considered not medically necessary.

• Applicable procedure codes referenced for authorization: 97129, 97130, S9056

Verify benefit coverage and prior authorization requirements

Before ordering or billing services, verify the member’s federal, state, and contractual benefit terms and any plan-specific prior authorization rules; UnitedHealthcare may use third‑party tools (for example, InterQual) to assist in administering benefits.

• Check the member’s benefit plan and any state-specific requirements prior to service authorization or scheduling.
• Confirm whether plan-specific prior authorization is required for CPT/HCPCS codes 97129, 97130, S9056.

Verify and document benefit eligibility and authorization before treatment

Confirm and document benefit eligibility and prior authorization status in the medical record and billing system prior to providing services to ensure coverage determinations align with the member’s federal/state/contractual plan terms.

• Document the authorization number and authorized visit limits when obtained.
• Reference the applicable CPT/HCPCS codes (97129, 97130, S9056) in the record and on claims.

Step therapy: none stated in this policy

No step therapy requirements are specified in this policy; do not assume step edits apply unless required by the member’s specific benefit plan or state contract.

• If the benefit plan enforces step edits, follow the plan’s step therapy process separately from this policy.

Document CPT/HCPCS codes and follow InterQual and Idaho visit-frequency guidance

Document use of applicable CPT/HCPCS codes (97129, 97130, S9056) in clinical notes and billing records; align the number and frequency of therapy visits with InterQual LOC: Outpatient Rehabilitation & Chiropractic and any Idaho-specific clinical coverage criteria from the Idaho Medicaid Provider Handbook.

• Record therapy modality, duration (initial 15 minutes for 97129; additional 15-minute increments for 97130), clinical goals, and response to treatment in each visit note.
• For S9056 (coma stimulation per diem), document the program components and clinical rationale, noting that coma stimulation is considered not medically necessary per policy.

Document and verify benefits against federal/state/contractual plan terms

Reference the applicable federal, state, or contractual benefit plan when applying this policy; documentation must support that services meet the member’s benefit terms and medical necessity criteria.

• Include clinical rationale, objective findings, and links to state-specific handbook criteria when submitting authorization requests or claims.
• Failure to reference applicable contractual or state requirements may result in denial or coverage exclusion.

Denial risk: coma stimulation likely denied as not medically necessary

Claims for coma stimulation (S9056) may be denied as not medically necessary because coma stimulation is unproven and considered not medically necessary for any Disorder of Consciousness due to insufficient evidence.

• If submitting S9056, include detailed documentation; be aware policy states coma stimulation is not medically necessary and denials are likely.
• Consider alternative, covered cognitive rehabilitation services (97129/97130) when clinically appropriate and supported by state criteria.

Benefit governance: follow federal/state/contractual terms when conflicts exist

When coverage terms conflict with this Medical Policy, the federal, state, or contractual requirements for the member’s benefit plan govern; follow those terms and document compliance with contractual/state rules.

• Review and follow state-specific Idaho Medicaid handbook provisions where applicable; in the event of conflict, the contractual/state terms supersede the policy.
• Document any deviations from the standard policy that are required by the member’s benefit contract.