Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Kentucky Only)
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State-specific UnitedHealthcare policy governing coverage criteria, codes, and documentation for habilitation, rehabilitation, and maintenance occupational, physical, and speech therapy services in Kentucky.
Supporting Information Updated Clinical Evidence and References sections to reflect the most current information.
Coverage and Medical Necessity Criteria
Medical Necessity Criteria (InterQual)
Medical necessity is determined using InterQual LOC criteria
Providers must refer to InterQual criteria for specific clinical decision rules.
State-Specific Criteria and Discharge
State-specific coverage and discharge considerations
See KAR for specifics.
Examples are not exhaustive.
General Coverage Criteria
Covered when services meet the definitions of rehabilitative or habilitative therapy and are supported by the member's plan terms and clinical documentation.
Documentation and plan-specific contractual/federal/state requirements apply.
This Medical Policy does not apply to cognitive therapy. For outpatient cognitive therapy services, providers should refer to the separate policy titled Cognitive Rehabilitation (for Kentucky Only) for coverage determinations and documentation requirements.
Maintenance therapy refers to services intended to prevent deterioration, promote health, and maintain or enhance quality of life when further clinical improvement is not reasonably expected. When ongoing care becomes supportive rather than corrective in nature, treatment is characterized as maintenance therapy and is subject to the policy's maintenance provisions and applicable benefit terms.
Continued therapy that cannot reasonably be expected to produce further clinical improvement is considered supportive care and aligns with the policy's description of maintenance therapy. Such continuation of therapy beyond the point where restorative benefit is unlikely may not meet rehabilitative intent and is addressed by the policy's limits for maintenance services; coverage depends on documentation showing therapeutic intent and plan-specific or regulatory requirements.
Applicable Procedure and Billing Codes
| 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 | Function, language comprehension, speech production ability, reading, spelling, writing assessment with interpretation and report, per hour. |
| 97761 | Orthotic(s) management and training, initial orthotic(s) encounter, each 15 minutes / Occupational therapy evaluation, low complexity, 15 minutes |
| 97763 | Orthotic(s)/prosthetic(s) management and/or training, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes |
| 97799 | Unlisted physical medicine/rehabilitation service or procedure |
| G0281 | Electrical stimulation (unattended) for chronic Stage III and IV pressure ulcers, arterial/diabetic/venous stasis ulcers not responding after 30 days of conventional care, as part of a therapy plan |
| G0283 | Electrical stimulation (unattended) for indications other than wound care, as part of a therapy plan |
| S8948 | Application of a modality (requiring constant provider attendance); low-level laser; each 15 minutes |
| S8990 | Physical or manipulative therapy performed for maintenance rather than restoration |
| S9129 | Occupational therapy, in the home, per diem |
| S9131 | Physical therapy, in the home, per diem |
| S9152 | Speech therapy, re-evaluation |
Provider Responsibilities and Billing Guidance
Follow InterQual LOC for medical necessity
Medical necessity for habilitation, rehabilitation, and maintenance therapy is determined using the InterQual® LOC: Outpatient Rehabilitation & Chiropractic criteria; providers must follow InterQual criteria for authorization decisions.
Use listed CPT/HCPCS codes and check benefit terms
Reference the policy's listed CPT/HCPCS codes when submitting requests, and verify federal, state, or contractual member benefit terms as they govern coverage and may affect authorization and payment.
- Policy code lists are provided for reference only and do not guarantee coverage or payment.
No step therapy specified in this policy section
This policy contains no step-therapy requirements in the document text; there are no specified step-therapy sequences in this policy section.
Third-party tools (e.g., InterQual) may drive utilization management
UnitedHealthcare may use third-party tools (for example, InterQual) to assist in administering benefits; such tools can implement utilization management approaches that could affect authorization determinations.
Comply with KAR § 907-008-040 documentation requirements
Providers must refer to Kentucky Administrative Regulations (KAR), § 907-008-040 for coverage, limits, and required documentation of occupational therapy, physical therapy, and speech-language pathology services in Kentucky.
- Ensure documentation meets KAR § 907-008-040 requirements when requesting coverage or submitting claims.
Provide professional episode-of-care documentation (APTA, ASHA)
Follow professional documentation standards and include an episode-of-care summary consistent with APTA and ASHA guidance to support coverage decisions and authorizations.
- Include admission/discharge criteria and a conclusion of episode-of-care summary per APTA and ASHA recommendations.
Code listing is not assurance of coverage
Listing a CPT/HCPCS code in this policy does not imply the service described is a covered benefit; benefit coverage is determined by applicable federal, state, or contractual requirements and laws.
- Do not assume inclusion in the policy guarantees reimbursement or authorization.
Unlisted or improper coding (e.g., 97799) risks denial
Use of codes not listed in the policy or use of unlisted/improper codes (for example, 97799) without justification and supporting documentation may result in denial.
- If submitting an unlisted code (e.g., 97799), include a clear description and documentation supporting medical necessity.
Key Definitions
Background and Purpose
Rehabilitative services are intended to improve, adapt, or restore functions impaired or permanently lost because of illness, injury, loss of a body part, or congenital abnormality. These services involve achievable goals within a reasonable period with assistance from a therapist or supervised therapy assistant and may include occupational, physical, or speech therapy. Habilitation services help individuals learn, keep, or improve skills needed for daily living (for example, therapy for a child not walking or talking at the expected age). Maintenance therapy seeks to prevent decline and preserve quality of life when further clinical improvement cannot reasonably be expected and treatment is supportive rather than corrective.
Policy Revision History
Supporting Information — Clinical Evidence and References sections updated; previous policy version CS164KY.09 archived.
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