The lists of procedure and diagnosis codes included in this policy are provided for reference only. Listing of a code does not imply that the service described by the code is a covered or non-covered health service, nor does inclusion guarantee payment or reimbursement. Coverage and payment determinations are made according to applicable federal, state, or contractual requirements and laws; refer to the member’s benefit plan and governing documents for final coverage decisions.

The presence of code S8990 in the document denotes a code used for physical or manipulative therapy performed for maintenance rather than restoration. This policy includes the code for reference; whether services billed with S8990 are covered depends on the applicable benefit plan and medical necessity rules. Providers should confirm coverage rules in the member’s benefit plan and applicable state or contractual requirements before billing maintenance-focused therapy.

This policy applies to UnitedHealthcare members in Nebraska and is governed by Nebraska Department of Health and Human Services medical necessity criteria for occupational, physical, and speech therapy. Coverage determinations must reference the Nebraska DHHS codes cited in the policy (e.g., the statutes referenced in the policy’s governance language) and comply with any applicable federal, state, or contractual requirements; where conflicts exist, those governing documents prevail.

The policy serves as an interpretive guide to those statutory medical necessity criteria rather than replacing them. Providers should use the DHHS medical necessity standards for OT, PT, and speech services when documenting and requesting services for Nebraska members and consult the member’s benefit plan for any additional coverage or authorization requirements.