UnitedHealthcare Outpatient OT/PT/SLP Prior Auth Update

Prior Authorization, Evaluation, Re-evaluation, Authorization and Discharge Criteria

General Prior Authorization and Documentation Requirements

Therapy services require prior authorization and documented evaluation/re-evaluation information. Authorization and documentation must meet all of the following:

ALL of the following

Prior authorization must be obtained before therapy is provided; claims without prior authorization will be denied.
Services must be provided by licensed practitioners (speech-language pathologist, provisionally licensed speech-language pathologist, licensed physical or occupational therapist) or home health agencies that employ/contract licensed therapists.
Requests for initial evaluations and therapy visits must be submitted by the Primary Care Provider (PCP) unless an authorization for the initial evaluation is already on file and the servicing provider submits subsequent requests.
Age-specific documentation for initial evaluation orders
- For members under 21 years: signed and dated physician order (less than 30 days old) specifying discipline(s) to be evaluated; current well child visit or exam note describing need; for speech initial evaluation under 6 years, documentation of a hearing screening per Florida EPSDT Periodicity Schedule or objective behavioral description/justification or documentation of audiology/physician referral if screening not possible or hearing deficit suspected.
- For members age 21 and older: signed and dated physician order (less than 30 days old) specifying discipline(s) to be evaluated; exam note describing need for evaluation(s).
Therapy evaluation report must accompany authorization requests for initial therapy visits and must be discipline-specific and include required elements: date of evaluation, patient identifiers, medical history/onset, functional impairment and impact on health/safety/independence, prior level of function vs current, diagnosis and prognosis, baseline objective measurements and standardized assessment scores as appropriate.
Plan of Care (POC) must accompany initial authorization, be signed and dated by referring provider (MD/DO/PA/NP or appropriate specialist), be based on evaluation results, and include required elements: evaluation date, patient identifiers, medical condition and diagnosis codes, medications, functional limitations, specific therapy, short/long-term measurable functional goals, frequency/length/duration, therapeutic methods/monitoring, diet if applicable, caregiver teaching, and coordination with other services.
POC must be signed and dated by the treating therapist.

ALL of the following

Prior authorization must be obtained before therapy is provided; claims without prior authorization will be denied.
Services must be provided by licensed practitioners (speech-language pathologist, provisionally licensed speech-language pathologist, licensed physical or occupational therapist) or home health agencies that employ/contract licensed therapists.
Requests for initial evaluations and therapy visits must be submitted by the Primary Care Provider (PCP) unless an authorization for the initial evaluation is already on file and the servicing provider submits subsequent requests.
Age-specific documentation for initial evaluation orders
- For members under 21 years: signed and dated physician order (less than 30 days old) specifying discipline(s) to be evaluated; current well child visit or exam note describing need; for speech initial evaluation under 6 years, documentation of a hearing screening per Florida EPSDT Periodicity Schedule or objective behavioral description/justification or documentation of audiology/physician referral if screening not possible or hearing deficit suspected.

ALL of the following

Prior authorization must be obtained before therapy is provided; claims without prior authorization will be denied.
Services must be provided by licensed practitioners (speech-language pathologist, provisionally licensed speech-language pathologist, licensed physical or occupational therapist) or home health agencies that employ/contract licensed therapists.
Requests for initial evaluations and therapy visits must be submitted by the Primary Care Provider (PCP) unless an authorization for the initial evaluation is already on file and the servicing provider submits subsequent requests.
Age-specific documentation for initial evaluation orders
- For members under 21 years: signed and dated physician order (less than 30 days old) specifying discipline(s) to be evaluated; current well child visit or exam note describing need; for speech initial evaluation under 6 years, documentation of a hearing screening per Florida EPSDT Periodicity Schedule or objective behavioral description/justification or documentation of audiology/physician referral if screening not possible or hearing deficit suspected.

Re-evaluation and Continuation Criteria

Re-evaluations and continuation requests must meet all of the following:

ALL of the following

Re-evaluations must be completed at least once every five (5) months and requests must be submitted by the PCP.
For re-evaluation requests, the PCP must submit a current well child exam or visit note documenting a face-to-face encounter with the PCP at least every six (6) months and a signed dated physician order (less than 30 days old) specifying disciplines to be re-evaluated.
Therapy re-evaluation report must include date of last therapy evaluation, patient identifiers, number of therapy visits authorized and attended, compliance to home program, description of current deficits with objective data, and objective demonstration of progress toward each treatment goal.
Updated POC/progress summary must be no older than 90 days for continuation requests.

Relevant CPT/HCPCS Codes and Coverage Status

Speech Therapy and Related Evaluation/Therapy CPT CodesCPTCovered

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	Assessment of aphasia with interpretation and report, per hour

Physical Medicine Modalities and Therapeutic ProceduresCPT|HCPCSCovered

97012	Traction, mechanical
97014	Electrical stimulation (unattended)
97016	Vasopneumatic devices
97018	Paraffin bath
97022	Whirlpool
97024	Diathermy
97026	Infrared
97028	Ultraviolet
97032	Electrical stimulation (manual), each 15 minutes
97033	Iontophoresis, each 15 minutes

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Therapeutic Procedures, PT/OT — Time-basedCPTCovered

97110	Therapeutic exercises, each 15 minutes
97112	Neuromuscular reeducation, each 15 minutes
97113	Aquatic therapy with therapeutic exercises
97116	Gait training, each 15 minutes
97139	Unlisted therapeutic procedure (specify)
97140	Manual therapy techniques, each 15 minutes
97150	Therapeutic procedures, group (2 or more individuals)

Evaluation and Re-evaluation CPT Codes (PT/OT)CPTCovered

97161	Physical therapy evaluation: low complexity
97162	Physical therapy evaluation: moderate complexity
97163	Physical therapy evaluation: high complexity
97164	Re-evaluation of physical therapy established plan of care
97165	Occupational therapy evaluation, low complexity
97166	Occupational therapy evaluation, moderate complexity
97167	Occupational therapy evaluation, high complexity
97168	Re-evaluation of occupational therapy established plan of care

Occupational Therapy and Assistive/Other CodesCPT|HCPCSCovered

97530	Therapeutic activities, direct (one-on-one), each 15 minutes
97535	Self-care/home management training, direct one-on-one, each 15 minutes
97542	Wheelchair management, each 15 minutes
97750	Physical performance test or measurement with written report
97755	Assistive technology assessment with written report
97760	Orthotic(s) management and training, initial encounter, each 15 minutes
97761	Prosthetic(s) training, initial encounter, each 15 minutes
97763	Orthotic/prosthetic management and/or training, subsequent encounter, each 15 minutes
97799	Unlisted physical medicine/rehabilitation service or procedure

HCPCS and Other CodesHCPCSCovered

G0281	Electrical stimulation (unattended) to one or more areas for chronic Stage III/IV pressure ulcers, arterial, diabetic, venous ulcers as part of POC after 30 days of conventional care
G0283	Electrical stimulation (unattended) for indications other than wound care as part of therapy POC
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

What Providers Must Do / Risk Areas

Prior Authorization

Obtain prior authorization before therapy

Prior authorization is required before providing any therapy services (evaluations and visits). Claims submitted without prior authorization will be denied. Initial evaluation prior authorization must be submitted by the Primary Care Provider (PCP); the servicing provider may submit requests for subsequent therapy visits only if an authorization for the initial evaluation was already obtained.

Initial evaluation prior authorization must be submitted by the PCP.
If no initial evaluation authorization is on file, requests for therapy visits must be submitted by the PCP.
Servicing provider may submit subsequent visit requests only when an initial evaluation authorization exists.

Documentation Required

Submit complete evaluation report and plan of care

Clinical and Administrative Context

This Florida-specific UnitedHealthcare policy establishes documentation and prior authorization requirements for outpatient occupational, physical, and speech therapy services and aligns the definition of Medical Necessity with the Florida Agency for Health Care Administration (AHCA). It references InterQual® LOC: Outpatient Rehabilitation & Chiropractic as the source for clinical coverage criteria and clarifies that therapy claims submitted without prior authorization will be denied.

The policy specifies practitioner and setting requirements: services must be provided by licensed speech-language pathologists, licensed physical or occupational therapists, or home health agencies that employ or contract licensed therapists, and evaluations may not be performed by therapy assistants. It also requires that prior authorization requests and required documentation (evaluation reports and a signed, dated Plan of Care) accompany initial authorization requests as described in the policy.

This policy does not apply to outpatient cognitive therapy; readers are directed to the Medical Policy titled Cognitive Rehabilitation for coverage and authorization requirements for cognitive therapy. Administrative updates noted that the discharge criteria wording was clarified to indicate the listed items are not exhaustive, and the prior policy version CS164FL.K was archived.

Numeric and Clinical Thresholds and Quick Metrics

Thresholds

Re-evaluation intervalat least once every 5 months

Updated POC/progress summary recency for continuationmust not be older than 90 days

Speech severity score thresholdsMild: -1 to -1.5 SD (85-78); Moderate: -1.5 to -2 SD (77-71); Severe/profound: >2 SD (<=70)

5 monthsMinimum interval for comprehensive re-evaluation

90 daysMax POC recency for continuation requests

26 weeksMax authorization duration for mild/moderate speech therapy (case-by-case)

Defined Terms

Definitions

Medical Necessity / Medically NecessaryCare, goods, or services that are necessary to protect life, prevent significant illness or disability, alleviate severe pain, are individualized and consistent with symptoms/confirmed diagnosis, consistent with generally accepted professional standards, not experimental, and not primarily for convenience. AHCA definition applies.

Plan of Care (POC)The documented therapy plan signed and dated by the referring provider and treating therapist including diagnosis, functional limitations, specific therapy, measurable goals, frequency/length/duration, therapeutic methods, and coordination with other services.

Standardized AssessmentObjective, norm-referenced or criterion-referenced tests appropriate to the member's condition (examples for speech: GFTA-3, PLS-5, CELF-5, OWLS-II, TOLD P-4, BBCS-R). Results are used to determine severity and authorization limits.

Policy Changes and Notes

2024-10-01content_added / archived_prior_versionLatest

Added language in the Introduction clarifying the policy does not apply to cognitive therapy and archived the previous policy version CS164FL.K.

2024-10-01clarification

Clarified Discharge Criteria language to state discharge criteria 'includes but is not limited to' the listed items (as applicable).

OpenPayer

Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) — Florida

Prior Authorization, Evaluation, Re-evaluation, Authorization and Discharge Criteria

Relevant CPT/HCPCS Codes and Coverage Status

What Providers Must Do / Risk Areas

Clinical and Administrative Context

Numeric and Clinical Thresholds and Quick Metrics

Defined Terms

Policy Changes and Notes

Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) — Florida

Prior Authorization, Evaluation, Re-evaluation, Authorization and Discharge Criteria

Relevant CPT/HCPCS Codes and Coverage Status

What Providers Must Do / Risk Areas

Clinical and Administrative Context

Numeric and Clinical Thresholds and Quick Metrics

Defined Terms

Also Review

Policy Changes and Notes