CurrentUnitedHealthcarePolicy CS164FL.M

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

Florida-specific UnitedHealthcare policy describing documentation, prior authorization, visit approval criteria, evaluation/re-evaluation requirements, and applicable CPT/HCPCS codes for outpatient speech, occupational, and physical therapy.

Policy Summary

PayerUnitedHealthcare

PolicyHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Florida Only)

Policy CodePolicy CS164FL.M

Change TypeReferences updated; non-material clarifications

Effective DateNov 1, 2025

Next Review Date

Key ActionPCP must submit prior authorization for initial evaluations and re-evaluations; without a PA on file before therapy is provided, claims will be denied.

SourceLink

POLICY UPDATE CHANGES

Updated reference link to Cognitive Rehabilitation and Coma Stimulation policy title.

Supporting information (References) updated to reflect most current information.

Florida onlyGeographic scope

PA requiredInitial evaluations and therapy visits

5 monthsMinimum comprehensive re-evaluation frequency

TieredAuthorization visit limits

Coverage and Medical Necessity Criteria

General Coverage Requirements

Therapy services (speech, occupational, physical) are covered when documentation, licensure, and medical necessity criteria are met and prior authorization is obtained:

ALL of the following

Service provided in Florida (policy applies only to FL members)
Provider is appropriately licensed (speech-language pathologist, provisionally licensed SLP under supervision, licensed PT or OT, or home health agency employing these clinicians)
Therapist-level evaluations (not assistants) perform evaluations
Services meet Florida AHCA definition of Medical Necessity
Prior authorization (PA) is obtained before therapy is provided; absence of PA leads to claim denial

Requests for Initial Evaluation — Submission Requirements

Prior authorization for initial evaluations must be submitted by the PCP and include the following depending on age:

Member age groups

Members under 21 years
- Signed and dated physician order, < 30 days old, specifying discipline(s) to be evaluated
- Current well child visit or exam note describing need for evaluation(s)
- Speech therapy under 6 years additional requirement
  - Documentation of hearing screening per Florida EPSDT periodicity schedule
  - If behavioral issues prevent hearing screen, include objective description of behavior and why hearing deficit is not suspected

Applicable CPT / HCPCS Codes

Speech therapy CPT/HCPCSCPT|HCPCS

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; 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, per hour (includes expressive/receptive language, reading, writing)

1–10 of 11

1/2

Physical & Occupational therapy CPT/HCPCSCPT|HCPCS

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

1–10 of 38

1/4

Other HCPCS / CPT codes referencedHCPCS|CPT

G0281	Electrical stimulation (unattended) for chronic Stage III/IV pressure ulcers/wounds not improving after 30 days of conventional care
G0283	Electrical stimulation (unattended) for indications other than wound care
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

What Providers Must Do

Prior Authorization

Prior authorization required for evaluations and therapy visits

Prior authorization must be obtained before therapy is provided. The PCP must submit prior authorization for initial evaluations and re-evaluations; if no PA is on file before therapy is provided, the therapy claim will be denied.

Prior Authorization

Authorization requester responsibility by setting

Prior authorization submission responsibilities differ by request type and setting: the PCP must submit prior authorization for initial evaluations in all service delivery settings; the servicing provider may submit authorization requests for initial therapy visits only when an authorization for an initial evaluation was previously obtained.

Numeric and Clinical Thresholds

Thresholds

Re-evaluation intervalAt least once every 5 months

Updated POC/progress summary recencyMust be no older than 90 days

Mild standardized assessment score−1 to −1.5 SD (score 85 to 78)

Moderate standardized assessment score−1.5 to −2 SD (score 77 to 71)

Severe/profound standardized assessment score> 2 SD (score 70 or below)

Clinical and Administrative Background

This Florida-specific policy operationalizes the Florida Agency for Health Care Administration (AHCA) definition of Medical Necessity and references the InterQual® LOC: Outpatient Rehabilitation & Chiropractic criteria for habilitation and rehabilitation outpatient therapy services. It applies only to services provided to members in Florida and clarifies that the InterQual criteria are used to inform medical necessity determinations for outpatient speech, occupational, and physical therapy (see related site-of-service guidance and the separate Cognitive Rehabilitation and Coma Stimulation policy for cognitive therapy).

Prior authorization (PA) workflows are specified: PCPs must submit PA requests for initial evaluations and re-evaluations for all settings; if no PA is on file before therapy is provided, claims will be denied. The servicing provider may submit authorization for initial therapy visits only when an evaluation authorization has already been obtained. Documentation requirements and signer responsibilities for both the evaluation and the plan of care (POC) are detailed and must be met for authorization.

The policy mandates use of standardized assessments or, when a standardized test is not possible, in‑depth objective clinical task analysis with supporting checklists or caregiver reports. Evaluation reports must include demographics, brief medical history/onset, functional impact, clear diagnosis and prognosis, and baseline objective measurements including current standardized assessment scores where applicable. The POC must be discipline‑specific, list specific measurable functional short‑ and long‑term goals, frequency/length/duration, therapeutic methods, caregiver teaching, coordination with other services, and signature/date requirements for both the treating therapist and referring provider.

Visit frequency and authorization limits are tiered by standardized assessment severity: Mild (−1 to −1.5 SD or score 85–78): up to 1 visit weekly, up to 26 weeks; Moderate (−1.5 to −2 SD or score 77–71): up to 2 visits weekly, up to 26 weeks; Severe/profound (> 2 SD or score 70 or below): up to 3 visits weekly, up to 13 weeks. Continued need beyond authorized duration requires follow-up via the re‑evaluation process.

Defined Terms

Definitions

Medical NecessityCare, goods, or services necessary to protect life, prevent significant illness/disability, or alleviate severe pain; individualized, consistent with diagnosis/symptoms, not experimental, reflective of service level that can be safely furnished, and not primarily for convenience.

EPSDT (Early and Periodic Screening, Diagnosis, and Treatment)Federal requirement to provide medically necessary services to eligible members under age 21 to correct or ameliorate defects, conditions, or illnesses; services exceeding standard policy may be approved if medically necessary.

Policy Updates

2026-03-01reference update / archivalLatest

Updated reference link to the Cognitive Rehabilitation and Coma Stimulation policy title and archived the prior version CS164FL.L.

2025-11-01supporting information update / archival

Updated supporting information (References) to reflect current information and archived the previous policy version CS164FL.L.

Policy Summary

PayerUnitedHealthcare

PolicyHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Florida Only)

Policy CodePolicy CS164FL.M

Change TypeReferences updated; non-material clarifications

Effective DateNov 1, 2025

Next Review Date

Key ActionPCP must submit prior authorization for initial evaluations and re-evaluations; without a PA on file before therapy is provided, claims will be denied.

SourceLink

On This Page

If suspected hearing deficit, include referral to audiologist/physician experienced in pediatrics and documentation of referral

Members 21 years and older

Signed and dated physician order, < 30 days old, specifying discipline(s) to be evaluated
Exam note describing the need for the requested evaluation(s)

Documentation Required

Evaluation and Plan of Care documentation requirements

The evaluation report and Plan of Care (POC) must be discipline-specific and include required elements such as member demographics, brief medical history and onset, functional impairment and prior vs current level, clear diagnosis and reasonable prognosis, baseline objective measurements or standardized assessment scores (or task analysis if tests not possible), and a POC with measurable, functional, time-based goals, frequency/length/duration, therapeutic methods, coordination, and signatures.

Evaluation: date of initial evaluation; member name, age, DOB; medical history including onset; review of systems; language exposure; functional impairment and impact; prior vs current level; diagnosis and prognosis; baseline objective measurements and standardized assessment scores or task analysis
POC: date of initial evaluation; demographics; medical condition and diagnostic codes; medications/treatments/equipment; functional limitations; specific therapy; short- and long-term measurable, functional, time-based goals; treatment frequency, length, and duration; therapeutic methods and monitoring criteria; caregiver teaching and coordination with other services
Signatures: POC signed and dated by treating therapist and signed and dated by referring provider (MD/DO/PA/NP or appropriate specialist)

Documentation Required

Re-evaluation and continuation documentation

Continuation/reevaluation authorization requests must include a recent re-evaluation and objective evidence of progress: date of last evaluation; visits authorized and attended; compliance with home program; objective description of current deficits and severity; objective demonstration of progress toward each treatment goal; and an updated POC/progress summary that is no older than 90 days.

Date of last therapy evaluation; member demographics; number of visits authorized and attended
Compliance to home program and objective data documenting current deficits and severity
Objective demonstration of progress toward each treatment goal; for unmet goals submit baseline and current function and explain barriers or reasons for modification/discontinuation
Updated individualized POC with measurable, functional, time-based goals; updated POC/progress summary must be ≤ 90 days old

Denial Risk

Denial risk for insufficient POC update

A revised POC that does not include a meaningful update to support the need for continued services will not be accepted and may result in denial of additional visits; percentage accuracy toward goals alone is insufficient to establish medical necessity for continued therapy.

Re‑evaluations must be completed at least every 5 months and PA requests for re‑evaluation must be submitted by the PCP. Continuation requests must include a recent re‑evaluation and objective evidence of progress toward each treatment goal, visit attendance, compliance with home program, an updated POC that is no older than 90 days, and explanations for any unmet goals. A revised POC that lacks a meaningful update will not be accepted and may lead to denial of additional visits.

The policy also specifies provider and supervision requirements (licensed SLPs, provisionally licensed SLPs under supervision, licensed PTs/OTs, and eligible home health agency staff), and lists common limitations and exclusions (for example, duplication of services, developing/updating the POC as a billable service, travel/mileage, telephone-only contacts except telemedicine per UnitedHealthcare policy, and treatment visits billed the same day as an evaluation).

This version reflects non‑material clarifications to reference links and supporting information updates noted in the policy history (most recent revision updated a reference link and archived the prior version).