Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesPhysical Medicine, Rehab & TherapiesUnitedHealthcare Habilitation Rehab Coverage Updat…
    Ask Trek AI about this page
    CurrentUnitedHealthcarePolicy CSNC.MP.164.05

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

    Customize your policy alerts

    Sign up for UnitedHealthcare Policy CSNC.MP.164.05 alerts

    Get alerted when Policy CSNC.MP.164.05 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Defines UnitedHealthcare's medical policy for habilitation and rehabilitation occupational, physical, and speech therapy services for members in North Carolina, referencing North Carolina Medicaid clinical coverage criteria and applicable CPT/HCPCS codes.

    Policy Summary
    PayerUnitedHealthcare
    PolicyHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for North Carolina Only)
    Policy CodePolicy CSNC.MP.164.05
    Change TypeRoutine reviewno change
    Effective DateAug 1, 2026
    Last ReviewAug 1, 2026
    Next Review Date
    Key ActionFollow North Carolina Medicaid Clinical Coverage Policy 10A for medical necessity determinations for outpatient specialized therapies.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    NC
    state applicability
    2026-08-01effective date
    No changerevision outcome
    NC Medicaid 10Aexternal criteria

    Coverage and Medical Necessity Criteria

    Medical necessity criteria (delegated to NC Medicaid 10A)

    Coverage and medical necessity are determined by adherence to North Carolina Medicaid Clinical Coverage Policy 10A for Outpatient Specialized Therapies.

    Delegated medical necessity: Therapy services are covered when they meet the medical necessity clinical coverage criteria set forth in the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Specialized Therapies, 10A: Outpatient Specialized Therapies.

    Policy defers to NC Medicaid 10A for clinical criteria.

    This Medical Policy does not apply to cognitive therapy. For outpatient cognitive therapy, refer to the Medical Policy titled Cognitive Rehabilitation and Coma Stimulation (for North Carolina Only).

    Relevant CPT / HCPCS Codes and Fee Schedule Notes

    Speech therapy CPT codes (excerpt)CPT
    92507Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual.
    92508Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals.
    92521Evaluation of speech fluency (e.g., stuttering, cluttering).
    92522Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria).
    92523Evaluation of speech sound production with evaluation of language comprehension and expression (e.g., receptive, and expressive language).
    92524Behavioral and qualitative analysis of voice and resonance.
    92526Treatment of swallowing dysfunction and/or oral function for feeding
    Therapy and modality CPT codes (excerpt)CPT
    97012Application of a modality to 1 or more areas; traction, mechanical.
    97014Application of a modality to 1 or more areas; electrical stimulation (unattended).
    97016Application of a modality to 1 or more areas; vasopneumatic devices.
    97018Application of a modality to 1 or more areas; paraffin bath.
    97022Application of a modality to 1 or more areas; whirlpool.
    97024Application of a modality to 1 or more areas; diathermy (e.g., microwave).
    97026Application of a modality to 1 or more areas; infrared.
    97028Application of a modality to 1 or more areas; ultraviolet.
    97032Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes.
    97033Application of a modality to 1 or more areas; iontophoresis, each 15 minutes.
    1–10 of 37
    1/4
    HCPCS / State-specific codes (some not on NC fee schedule)HCPCS
    G0281Electrical stimulation (unattended) to one or more areas for chronic Stage III/IV pressure ulcers, arterial ulcers, diabetic ulcers, venous stasis ulcers as part of a therapy plan of care.
    G0283Electrical stimulation (unattended) to one or more areas for indications other than wound care, as part of a therapy plan of care.
    S8948Application of a modality (requiring constant provider attendance); low-level laser; each 15 minutes.
    S8990Physical or manipulative therapy performed for maintenance rather than restoration.
    S9129Occupational therapy, in the home, per diem.
    S9131Physical therapy; in the home, per diem.
    S9152Speech therapy, re-evaluation.
    inv-06: NC Fee Schedule exclusion — codes marked with an asterisk note
    NC Fee Schedule exclusionCodes marked with an asterisk (*) are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.
    Examples of asterisked codesG0281, G0283, S8948, S8990, S9129, S9131, S9152 are listed in the policy with an asterisk indicating they are not on the NC Medicaid Fee Schedule.
    Implication for coverageAbsence from the NC Medicaid Fee Schedule means these codes may not be reimbursable under NC Medicaid — check state fee schedule and member benefit contract for coverage determinations.

    Provider Responsibilities and Billing Considerations

    Prior Authorization

    Prior authorization governed by benefit contract

    Check the member's specific benefit plan, including federal, state or contractual requirements, to determine whether prior authorization is required — this policy lists codes for reference but does not itself establish prior authorization rules.

    • Prior authorization requirements are governed by the member's benefit contract and applicable federal/state rules.
    • This policy's code lists are for reference only and do not replace benefit verification.
    Step Therapy

    No step therapy requirements specified

    There are no step therapy requirements specified in this policy document.

    Policy Background and Scope

    This policy governs habilitation and rehabilitation services — occupational, physical, and speech therapy — for outpatient settings in North Carolina only. Medical necessity and clinical coverage criteria for these outpatient specialized therapies are delegated to and must be determined by the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Specialized Therapies, 10A: Outpatient Specialized Therapies.

    Definitions and Scope Exclusions

    inv-12: Cognitive therapy exclusion — referral to Cognitive Rehabilitation policy for outpatient cognitive therapy
    Policy scope exclusionThis Medical Policy does not apply to cognitive therapy.
    Where to refer outpatient cognitive therapyRefer to the Medical Policy titled 'Cognitive Rehabilitation and Coma Stimulation (for North Carolina Only)' for outpatient cognitive therapy coverage and criteria.
    Medical necessity referenceFor other therapy medical necessity criteria, the policy defers to North Carolina Medicaid Clinical Coverage Policy 10A: Outpatient Specialized Therapies.
    Policy Summary
    PayerUnitedHealthcare
    PolicyHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for North Carolina Only)
    Policy CodePolicy CSNC.MP.164.05
    Change TypeRoutine reviewno change
    Effective DateAug 1, 2026
    Last ReviewAug 1, 2026
    Next Review Date
    Key ActionFollow North Carolina Medicaid Clinical Coverage Policy 10A for medical necessity determinations for outpatient specialized therapies.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaRelevant CPT / HCPCS Codes and Fee Schedule NotesProvider Responsibilities and Billing ConsiderationsPolicy Background and ScopeDefinitions and Scope Exclusions
    Documentation Required

    Reference governing benefit documents

    When determining coverage for a member, reference the federal, state or contractual benefit requirements that apply to that member; if those requirements conflict with this Medical Policy, the federal, state or contractual requirements govern.

    • Verify and follow the member's governing federal, state, or contractual benefit documents before applying this policy.
    • In the event of a conflict, the federal, state, or contractual requirements for benefit plan coverage take precedence.
    Denial Risk

    Code listing does not guarantee coverage or payment

    Listing a procedure or diagnosis code in this policy does not guarantee that the service is covered or that the claim will be paid; coverage and reimbursement are determined by applicable federal, state, or contractual requirements and laws.

    • Inclusion of a code in the policy is for reference only and does not imply a right to reimbursement.
    • Other policies, guidelines, or benefit terms may apply and affect coverage/payment.