CurrentUnitedHealthcarePolicy CS164KY.09

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

Kentucky-specific UnitedHealthcare medical policy defining coverage considerations, state-specific references, discharge criteria, speech/language considerations (including bilingual testing requirements), applicable CPT/HCPCS codes, and use of InterQual LOC for medical necessity. Applies only to Kentucky.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS164KY.09

Change TypeRevisions and additions to discharge and speech/language guidanceadded Clinical Evidence

Effective DateDec 1, 2025

Next Review Date

Key ActionApply InterQual LOC: Outpatient Rehabilitation & Chiropractic for medical necessity determinations and document compliance with Kentucky KAR § 907-008-040, including required documentation of OT/PT/SLP services.

SourceLink

POLICY UPDATE CHANGES

Revised list of discharge criteria; replaced 'functional abilities have become comparable to those of others of the same chronological age and gender' with 'functional abilities have become comparable to individuals of the same chronological age'.

Added speech and language considerations language regarding bilingual and multilingual speakers, testing requirements for limited English proficiency, and dyslexia documentation requirements.

Added Clinical Evidence section and updated Description of Services and References; removed Benefit Considerations section.

Added related policy reference links including Cochlear Implants, Durable Medical Equipment/Orthotics, and Home Health Care Services (for Kentucky Only).

~50Procedure/HCPCS/CPT codes listed

State-limitedApplicability

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InterQualClinical criteria source

Coverage Summary

Kentucky-specific UnitedHealthcare coverage policy (Policy No. CS164KY.09) applies only to occupational, physical, and speech-language therapy services in Kentucky. The policy uses InterQual® LOC: Outpatient Rehabilitation & Chiropractic as the clinical criteria source for medical necessity determinations and references Kentucky Administrative Regulations (KAR § 907-008-040) for state-specific coverage, limits, and documentation requirements. This policy explicitly does not apply to cognitive therapy (outpatient cognitive therapy is covered under a separate Kentucky policy).

Policy metadata

policy_numberCS164KY.09

subjectHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) for Kentucky

effective_date2025-12-01

last_review2026-05-01

state_applicabilityKentucky only

clinical_criteria_sourceInterQual® LOC: Outpatient Rehabilitation & Chiropractic; Kentucky Administrative Regulations (KAR) § 907-008-040

Medical Necessity / Coverage Criteria

General Coverage / Medical Necessity

Habilitation, rehabilitation, and maintenance services are considered medically necessary in certain circumstances per InterQual LOC and Kentucky Administrative Regulations.

ALL of the following

Services must meet medical necessity clinical coverage criteria per InterQual ® LOC: Outpatient Rehabilitation & Chiropractic
Services must conform to Kentucky Administrative Regulations (KAR) § 907-008-040 for coverage, limits, and required documentation of OT, PT, and speech-language pathology services
State regulation governs specific coverage and limits
Policy does not apply to cognitive therapy; outpatient cognitive therapy is governed by separate policy 'Cognitive Rehabilitation and Coma Stimulation (for Kentucky Only)'

Discharge Criteria

CPT / HCPCS Codes

Referenced CPT / HCPCS Procedure Codes (for OT/PT/SLP services and modalities)CPT

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

1–10 of 55

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Provider Actions / Documentation Requirements

Documentation Required

Use InterQual criteria and state regulations

Apply the InterQual® Level of Care: Outpatient Rehabilitation & Chiropractic as the primary clinical criteria for medical necessity determinations. Also ensure documentation demonstrates compliance with Kentucky Administrative Regulations (KAR) § 907-008-040 for coverage, limits, and required documentation of OT, PT, and speech-language pathology services.

Documentation Required

Bilingual testing and service delivery documentation

For individuals with limited English proficiency, document the language of highest proficiency and provide culturally and linguistically adapted, norm-referenced testing in all languages the child is exposed to. Document that speech/language deficits are present in the language of highest proficiency and that services are delivered in the language of highest receptive language proficiency.

Perform adapted norm‑referenced testing in all languages the child is exposed to
Document the language of highest proficiency
Document the language in which services are delivered (must be the language of highest receptive proficiency)

Background & Clinical Evidence

This Kentucky-only policy defines three therapy types: Habilitation services (services that help a person keep, learn, or improve daily living skills), Rehabilitative services (services intended to improve, adapt, or restore function lost or impaired by illness, injury, or congenital abnormality), and Maintenance therapy (services to prevent deterioration when further clinical improvement is not reasonably expected and treatment is supportive rather than corrective). The Description of Services clarifies that these may include occupational, physical, and speech therapy across applicable settings. The policy excludes outpatient cognitive therapy and directs users to the separate Cognitive Rehabilitation and Coma Stimulation policy. It is state-limited and requires conformity with Kentucky Administrative Regulations for coverage, limits, and required documentation.

The Clinical Evidence section summarizes studies on bilingual speech development and diagnostic accuracy that inform the policy. Key cited studies include Erikson et al. (2021) and multiple studies by Fabiano-Smith et al. (2010, 2018), and Gildersleeve-Neumann et al. (2008), which examine phonological development, risk of misdiagnosis in bilingual children, and between-language interaction in bilingual speech acquisition.

Definitions

Habilitation servicesHealth care services that help a person keep, learn, or improve skills and functioning for daily living.

Rehabilitative servicesServices intended to improve, adapt, or restore functions impaired or lost due to illness, injury, or congenital abnormality.

Revision History

2025-12-01revised

Revised discharge criteria: replaced 'functional abilities have become comparable to those of others of the same chronological age and gender' with 'functional abilities have become comparable to individuals of the same chronological age' (is_material: true).

2025-12-01added

Added speech and language considerations language (relocated from Benefit Considerations): bilingual/multilingual speakers guidance, culturally and linguistically adapted norm-referenced testing for limited English proficiency, required criteria for service delivery language, and dyslexia documentation requirements (is_material: true).

2025-12-01

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS164KY.09

Change TypeRevisions and additions to discharge and speech/language guidanceadded Clinical Evidence

Effective DateDec 1, 2025

Next Review Date

SourceLink

On This Page

Discharge is appropriate when ALL of the applicable conditions below are met (includes but not limited to):

Any one of the following may justify discharge

Treatment goals and objectives have been met
Functional abilities have become comparable to individuals of the same chronological age
The desired level of function that has been agreed to by the individual and provider has been achieved
The skill of a therapist or other licensed healthcare professional (within the scope of his/her licensure) is not required
The individual exhibits behavior that interferes with improvement or participation in treatment and efforts to address these factors have not been successful
The individual, family, or designated guardian chooses not to participate, relocates, or seeks another provider (provided they have been advised of likely outcomes of discontinuation)
The individual is transferred or discharged to another location where ongoing service from the current provider is not reasonably available (efforts should be made to ensure continuation of services in new locale)
The individual is unable to tolerate treatment because of a serious medical, psychological, or other condition

Speech and Language Services — Limited English Proficiency / Bilingual Considerations

For individuals with limited English proficiency, ALL of the following must be met:

ALL of the following

All speech deficits must be present in the language in which the individual has the highest proficiency
Language deficits must be present in the language in which the individual has the highest proficiency
Delivery of services must be in the language in which the individual has the highest receptive language proficiency

Documentation for Dyslexia

When dyslexia is present:

ALL of the following

Test results substantiating a diagnosis of receptive or expressive language delay must be included
Goals must address the corresponding language deficits

Documentation Required

Dyslexia-related documentation

When dyslexia is present, include test results that substantiate a diagnosis of receptive or expressive language delay and ensure treatment goals explicitly address the corresponding language deficits.

Maintenance therapyServices to prevent deterioration of a chronic condition when further clinical improvement cannot reasonably be expected; supportive rather than corrective care to maintain function.

Added Clinical Evidence section and updated Description of Services and References; removed Benefit Considerations section (is_material: false).

2025-12-01addedLatest

Added related policy reference links including Cochlear Implants, Durable Medical Equipment/Orthotics, and Home Health Care Services (for Kentucky Only) (is_material: false).