ModifiedUnitedHealthcarePolicy CS164NM.C

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

Governs coverage and documentation requirements for outpatient habilitation and rehabilitation therapy (OT, PT, ST) for members in New Mexico; does not apply to cognitive therapy. Affects providers requesting evaluations, plans of care, continuation, re-evaluations, and documentation for authorization.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS164NM.C

Change TypeMaterial and non‑material revisions (LEP speech/language criteria added; clinical evidence and housekeeping updates)

Effective DateNovember 1, 2025

Next Review DateN/A

Key ActionSubmit an initial authorization that includes an evaluation and a plan of care with frequency, duration, and measurable goals (UnitedHealthcare may authorize up to 6 months upon clinical review).

SourceLink

POLICY UPDATE CHANGES

Added language clarifying assessment and service delivery requirements for bilingual and multilingual speakers and requirements for culturally and linguistically adapted testing.

Clinical Evidence section added summarizing several studies on bilingual speech/phonological development.

Updated Description of Services and References sections to reflect current information.

Benefit Considerations section was removed from the policy.

Corrected typographical errors in Clinical Evidence and other sections.

NM onlypolicy application state

6 monthsmax auth period

Every 6 monthsre-eval frequency

90 daysPOC recency limit

NM-specificNM-specific references

Coverage and Medical Necessity Criteria

Medical Necessity and Documentation Criteria

Covered when ALL of the following are met and per InterQual LOC criteria:

Initial evaluation and referral: Provider must have PCP (MD, DO, PA, or NP) or appropriate specialist referral/order on file prior to completion of the evaluation unless state-exempt

From Initial Therapy Evaluation/Initial Therapy Visit Requests

Evaluation content: Evaluation report must include the individual's medical history and a comparison of prior level of function to current level of function, and must document diagnosis with appropriate ICD-10 code and relevant baseline objective measurements (standardized assessments or justified alternatives)

From Initial Therapy Evaluation/Initial Therapy Visit Requests

Plan of Care: A plan of care (POC) developed from the evaluation must include the functional or physical impairment, specific measurable short- and long-term goals that are functional, measurable, attainable and time-based, treatment frequency, duration, and anticipated session length

From Plan of Care

Continuation criteria: Requests for continuation must include prior weeks/visits authorized and attended, the member's current status versus evaluation baseline with objective measures of performance in functional terms, comparison of current physical/functional status to prior measurements, demonstration of continued impairment versus normal or premorbid function, and rationale for continued skilled services

From Requests for Continuation of Therapy Visits

Re-evaluations must be completed at least once every six months (or more frequently per state requirements), include current standardized assessment scores or other objective measures, documentation of progress toward goals, an updated POC (the updated POC/progress summary must not be older than 90 days), and a brief prognosis with discharge criteriaat least once every six months; updated POC/progress summary <= 90 days

From Re-Evaluations

InterQual clinical criteria: Medical necessity determinations are governed by InterQual® LOC: Outpatient Rehabilitation & Chiropractic and UnitedHealthcare may use InterQual to assist coverage decisions

Referenced clinical criteria source and authorization guidance

Speech and language therapy — LEP criteria

For speech and language therapy services for an individual with limited English proficiency, ALL of the following must be met:

Speech/Language for LEP individuals: 1) All speech deficits must be present in the language in which the individual has the highest proficiency; 2) Language deficits must be present in the language in which the individual has the highest proficiency; 3) Delivery of services must be in the language in which the individual has the highest receptive language proficiency.

Relocated from Benefit Considerations to Coverage Rationale

This policy does not apply to cognitive therapy. Outpatient cognitive therapy is governed by the separate Medical Policy titled "Cognitive Rehabilitation and Coma Stimulation (for New Mexico Only)." For medical necessity clinical coverage criteria for habilitation and rehabilitation therapies, refer to the InterQual® LOC: Outpatient Rehabilitation & Chiropractic.

Services that are provided solely to maintain a current level of function, when further clinical improvement cannot reasonably be expected, are characterized as maintenance therapy. Maintenance therapy is considered supportive rather than corrective when the ongoing care’s purpose is to prevent decline or promote general health rather than to restore lost function; such distinction affects how services are evaluated under this policy.

Services are appropriate for discharge (i.e., not medically necessary to continue) when one or more of the following apply: treatment goals and objectives have been met; functional abilities are comparable to peers of the same chronological age; the agreed-upon desired level of function has been achieved; the skill of a therapist is no longer required; interventions to address persistent behaviors that interfere with participation have been unsuccessful; or the individual, family, or guardian requests discontinuation or relocates and continuation with the current provider is not reasonably available.

HCPCS code S8990 is described as physical or manipulative therapy performed for maintenance rather than restoration. Because maintenance therapy is defined as care intended to preserve current function or prevent deterioration when further improvement is not expected, services reported with S8990 reflect maintenance-level interventions and may be evaluated differently than restorative therapy when applying coverage and medical necessity criteria.

Applicable Codes, Frequency, and Billing Rules

Applicable CPT CodesCPT

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 (e.g., receptive and expressive language).
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.

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Occupational therapy evaluation codesCPTCovered

97165	Occupational therapy evaluation, low complexity
97166	Occupational therapy evaluation, moderate complexity
97167	Occupational therapy evaluation, high complexity

Therapy and assessment CPT codesCPTCovered

97168	Re-evaluation of occupational therapy established plan of care
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, each 15 minutes
97755	Assistive technology assessment with written report, each 15 minutes

Additional CPT/HCPCS/S codesmixedCovered

97760	Orthotic(s) management and training, initial encounter, each 15 minutes
97761	Prosthetic(s) training, initial prosthetic encounter, each 15 minutes
97763	Orthotic(s)/prosthetic(s) management and/or training, subsequent encounter, each 15 minutes
97799	Unlisted physical medicine/rehabilitation service or procedure
G0281	Electrical stimulation (unattended) for chronic nonhealing ulcers after 30 days of conventional care
G0283	Electrical stimulation (unattended) for indications other than wound care
S8948	Low-level laser modality, 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

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inv-11: Re-evaluation frequency

Re-evaluation intervalRe-evaluations must be completed at least once every six months (or more frequently per state regulatory requirements)

Required contentRe-evaluation must include current standardized assessment scores, percent functional delay or criterion-referenced scores, objective demonstration of progress toward each treatment goal, and a brief prognosis with discharge criteria

Documentation elementsTherapy re-evaluation report must list date of last evaluation, authorized and attended visits, compliance to home program, and description of current deficits with objective data

inv-12: Updated POC recency

POC recency requirement

Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization is required for therapy services when indicated by the plan. Prior authorization requests must include a completed evaluation and an individualized plan of care (POC). Upon clinical review and when appropriate, UnitedHealthcare may authorize therapies based on medical necessity criteria for up to six months. Authorization periods beyond initial approval will follow medical necessity review and applicable federal/state/contractual requirements.

Initial authorization must include the evaluation report and a POC with specific short- and long-term goals, treatment frequency, duration, and anticipated session length.
Authorizations may be granted for up to six months when clinical criteria are met.
Providers should verify member benefits and any state or contractual exceptions before submitting an authorization request.

Note

Background and Policy Scope

Habilitation and rehabilitation therapies — including occupational therapy (OT), physical therapy (PT), and speech-language pathology (ST) — are intended to restore, improve, adapt, or teach skills and function for individuals with physical, speech, or occupational impairments. Rehabilitative services focus on improving, adapting, or restoring lost or impaired functions following illness, injury, or congenital conditions and typically involve measurable goals achievable within a reasonable time with therapist assistance. Habilitation services help individuals learn, maintain, or improve skills for daily living (for example, interventions for a child not walking or talking at expected ages). Maintenance therapy seeks to prevent decline or preserve current function when further improvement is unlikely, and when care becomes supportive rather than corrective, it is considered maintenance rather than rehabilitative.

Key Definitions and References

inv-23: InterQual LOC

InterQual LOC referencedInterQual® LOC: Outpatient Rehabilitation & Chiropractic is the clinical coverage criteria source used to determine medical necessity for outpatient habilitation and rehabilitation therapy

Role in decisionsPolicy directs providers to InterQual LOC for medical necessity clinical coverage criteria

ScopeInterQual LOC applies to outpatient rehabilitation and chiropractic services within this policy's coverage rationale

inv-24: Rehabilitative services

PurposeRehabilitative services are intended to improve, adapt, or restore functions impaired or permanently lost due to illness, injury, loss of a body part, or congenital abnormality

Examples of services

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS164NM.C

Change TypeMaterial and non‑material revisions (LEP speech/language criteria added; clinical evidence and housekeeping updates)

Effective DateNovember 1, 2025

Next Review DateN/A

SourceLink

On This Page

An updated individualized plan of care (POC)/progress summary must not be older than 90 days

When to revise POCIf majority of goals were not achieved, POC must describe barriers or explain why goals were modified or discontinued

Insufficient updatesA revised POC that lacks a meaningful update will not be accepted; percentage accuracy alone is insufficient to justify continued services

inv-13: Wound healing trial for G0281

G0281 indicationG0281 is defined for unattended electrical stimulation for chronic Stage III/IV pressure ulcers, arterial, diabetic, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care

Required trial periodMember must have had at least 30 days of conventional care without measurable signs of healing before G0281 is considered

Context of useG0281 is billed as part of a therapy plan of care for chronic nonhealing ulcers

Verify Benefits and Prior Authorization

Providers must verify benefits and prior authorization requirements before providing services. Coverage decisions are governed by federal, state, and contractual requirements; in the event of a conflict, those requirements govern. Failure to follow the applicable federal/state/contractual rules or to obtain required prior authorization may result in claim denials.

Check federal/state/contractual plan terms for coverage differences and any exemptions.
Verify whether state rules (e.g., NMAC 8.325.8 for New Mexico) or Alternative Benefit Package (ABP) rules apply to the member.
Confirm prior authorization status and any limitations before initiating treatment.

Documentation Required

Required Documentation

Providers are responsible for obtaining and maintaining required documentation. Required documentation must be submitted with authorization requests and retained in the medical record. Missing or incomplete documentation may lead to denial of services.

Required referral/order from a PCP or appropriate specialist (MD, DO, PA, NP) must be on file prior to completion of the evaluation unless state-exempt.
Complete initial therapy evaluation report including medical history, diagnosis with appropriate ICD-10 code, comparison of prior and current function, and baseline objective measurements.
A Plan of Care (POC) that includes functional impairment, measurable short- and long-term goals, treatment frequency, duration, and anticipated session length.
Re-evaluations at least every six months (or per state requirements) with updated standardized assessment scores, progress toward goals, and revised POC when appropriate.
All treatment session notes documenting date, specific treatments matching billed CPT codes, accurate session length, response to treatment, progress toward goals, and signature/date of treating provider.

Denial Risk

Common Missing Items That May Cause Denial

Common missing items that can cause denials: missing referral/order, incomplete evaluation report, absent or noncompliant POC elements, or outdated re-evaluation/progress documentation. Providers should ensure submissions include all required elements to support medical necessity.

Missing prescribing provider referral/order for evaluation or group therapy.
Incomplete evaluation (missing medical history, functional impact, or objective baseline measures).
POC lacking measurable, functional, time-based goals or missing treatment frequency/duration details.
Re-evaluation/progress summaries older than required intervals or lacking objective demonstration of progress.

Documentation Required

Documentation Standards

Documentation standards and clinical references: Accurate documentation of session length and adherence to professional documentation guidelines (AOTA/APTA/ASHA) are expected. Documentation will be used, in addition to InterQual, to assess medical necessity but does not guarantee coverage.

Follow AOTA, APTA, and ASHA guidance for clinical documentation, including accurate session timing and objective progress reporting.
Documentation submitted for review should align with InterQual criteria where applicable, but plan/contract rules and state regulations take precedence.

Denial Risk

Governance and Denial Risk

Governance and Denial Risk: Coverage decisions must follow the applicable federal, state, and contractual requirements. Noncompliance with these requirements, failure to obtain required authorizations, or insufficient documentation may result in denial or nonpayment.

In event of conflict, federal/state/contractual plan terms override this policy.
Providers are responsible for confirming and following any state-specific rules (e.g., New Mexico regulations) and ABP provisions that may affect coverage.
Denials may occur if required referrals, evaluations, or POCs are missing, incomplete, or if requested services do not meet medical necessity criteria.

Note

Reserved

Reserved: Additional provider actions or notes may be added here as needed.

Step Therapy

Step Therapy: No specific step therapy requirements are stated in this policy. Providers should verify whether any plan- or state-level step therapy rules apply to the member's benefits.

If step therapy applies under the member's contract, providers must follow applicable step requirements prior to authorization.

Services may include occupational, physical, or speech therapy and involve goals achievable in a reasonable period with therapist assistance

DeliveryServices may be provided by a therapist or therapy assistant under therapist supervision in various settings

inv-25: Habilitation services

DefinitionHabilitation services help a person keep, learn, or improve skills and functioning for daily living (e.g., therapy for a child not walking or talking at expected age)

Modalities includedMay include physical and occupational therapy, speech-language pathology, and other services for individuals with disabilities

SettingsProvided in a variety of inpatient and/or outpatient settings

inv-26: Maintenance therapy

DefinitionMaintenance therapy seeks to prevent disease progression, promote health, and maintain or prevent deterioration of a chronic condition when further clinical improvement is not reasonably expected

When considered maintenanceTreatment is considered maintenance when care becomes supportive rather than corrective because further improvement cannot reasonably be expected

Regulatory noteFor maintenance therapy, refer to New Mexico Administrative Code (NMAC) 8.325.8: Specialty Services, Rehabilitation Service Providers