ModifiedUnitedHealthcare Community PlanPolicy CS164NM.D

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

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Coverage and authorization of occupational, physical, and speech habilitation and rehabilitation therapy for UnitedHealthcare Community Plan members in New Mexico, including medical-necessity criteria, documentation requirements, authorization limits, discharge considerations, and applicable procedure codes.

Policy Summary

PayerUnitedHealthcare Community Plan

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

Policy CodePolicy CS164NM.D

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionSubmit an evaluation-based plan of care with the initial authorization request, including the impairment, measurable goals, treatment frequency and duration, and anticipated session length.

SourceLink

POLICY UPDATE CHANGES

Content and language pertaining to requests for continuation of therapy visits were removed from the Coverage Rationale.

Language requiring a primary care provider or appropriate specialist referral before completion of a speech, physical, or occupational therapy evaluation was removed.

The re-evaluation documentation list was updated by replacing “compliance to home program” with “adherence to home program.”

The Clinical Evidence and References sections were updated with current information.

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ModifiedUnitedHealthcare Community PlanPolicy CS164NM.D

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

Customize your policy alerts

Sign up for UnitedHealthcare Policy CS164NM.D alerts

Get alerted when Policy CS164NM.D changes without checking for updates manually.

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Policy Summary

PayerUnitedHealthcare Community Plan

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

Policy CodePolicy CS164NM.D

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionSubmit an evaluation-based plan of care with the initial authorization request, including the impairment, measurable goals, treatment frequency and duration, and anticipated session length.

SourceLink

POLICY UPDATE CHANGES

Content and language pertaining to requests for continuation of therapy visits were removed from the Coverage Rationale.

Language requiring a primary care provider or appropriate specialist referral before completion of a speech, physical, or occupational therapy evaluation was removed.

The re-evaluation documentation list was updated by replacing “compliance to home program” with “adherence to home program.”

The Clinical Evidence and References sections were updated with current information.

New MexicoState applicability

Up to 6 monthsPotential authorization period

Every 6 monthsMinimum re-evaluation frequency

90 daysMaximum updated plan age

3Therapy disciplines

Coverage Criteria

General coverage

Covered when all applicable medical-necessity requirements are satisfied.

Medical necessity

Coverage requirements
- Habilitation or rehabilitation therapy must be proven and medically necessary in the circumstances presented.
- The request must satisfy the applicable InterQual LOC: Outpatient Rehabilitation & Chiropractic clinical coverage criteria.

Initial therapy

Initial therapy requests must include all of the following clinical and treatment-planning elements:

Initial evaluation and plan of care

The therapy evaluation report includes the individual's medical history.
The report compares the prior level of function with the current level of function, as applicable.
The report describes the functional impairment and its impact on health, safety, and/or independence.
The report states a clear diagnosis with the appropriate ICD-10 code.
The report provides a reasonable prognosis, including the individual's potential for meaningful and noteworthy progress.
Baseline objective assessment
- ONE of
  - Current standardized assessment scores, age equivalents, percentage of functional delay, criterion-referenced scores, or other objective information appropriate to the condition or impairment are provided.
  - If standardized testing cannot be completed because of the individual's medical condition, the therapist provides in-depth objective clinical information using task analysis and, as appropriate, checklists, caregiver reports or interviews, and clinical observation.
Any standardized assessment used corresponds to the identified delays and relates to the short- and long-term goals.
Initial plan of care
- The plan of care identifies the functional or physical impairment.
- The plan of care includes short- and long-term therapeutic goals and objectives that are specific to the diagnosed condition or impairment, functional, measurable, attainable, time based, and related to individual-specific functional skills.
- The plan of care specifies treatment frequency and duration and the anticipated length of treatment sessions.

Continuation therapy

Continued therapy requires a current re-evaluation and documentation demonstrating ongoing medical necessity.

Continued therapy

A re-evaluation is completed at least once every 6 months, or more frequently when required by state regulation.at least once every 6 months
The re-evaluation includes the date of the last therapy evaluation, authorized and attended visit counts, adherence to the home program, and objective documentation of current deficits and their severity.
The re-evaluation objectively demonstrates progress toward each short- and long-term treatment goal using consistent and comparable methods, including baseline and current function for unmet goals.
The re-evaluation includes updated treatment modalities and recommended frequency and duration, a brief prognosis, clearly established discharge criteria, and an updated individualized plan of care with measurable, functional, and time-based goals.

Feeding and swallowing services

Feeding and swallowing services require an evaluation that supports clinical assessment, treatment candidacy, and an individualized treatment or management plan.

Feeding and swallowing evaluation

The evaluation includes an interview or case history.
The evaluation includes relevant medical and clinical records, including the potential impact of medications, if any.
The evaluation includes a physical examination and previous screenings and assessments.
The evaluation documents collaboration with providers and other caregivers.
Treatment candidacy or management is assessed based on medical stability, cognitive status, nutritional status, and psychosocial, environmental, and behavioral factors.

Cognitive therapy is not covered under this policy. Outpatient cognitive therapy should be addressed under the separate Cognitive Rehabilitation and Coma Stimulation (for New Mexico Only) policy.

Maintenance therapy is not governed by this policy’s primary medical-necessity criteria. Refer to New Mexico Administrative Code § 8.325.8, Specialty Services, Rehabilitation Service Providers, for applicable requirements.

Continued therapy is not supported when the revised plan of care does not contain a meaningful update demonstrating ongoing need. A progress report limited to percentage accuracy toward goals is insufficient by itself to establish the medical necessity of continued therapy.

Applicable Codes and Authorization Parameters

Applicable procedure codesCPT

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92521	Evaluation of speech fluency (e.g., stuttering, cluttering)
92523	Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria), with evaluation of language comprehension and expression
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, including assessment of expressive and receptive speech and language function, with interpretation and report, per hour
97012	Application of a modality to 1 or more areas; traction, mechanical
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended)
97016	Application of a modality to 1 or more areas; vasopneumatic devices

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Applicable CPT CodesCPTCovered

97110	Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
97112	Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.
97139	Unlisted therapeutic procedure (specify).
97140	Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes.
97150	Therapeutic procedure(s), group (2 or more individuals).
97161	Physical therapy evaluation: low complexity; typically, 20 minutes are spent face-to-face with the patient and/or family.
97162	Physical therapy evaluation: moderate complexity; typically, 30 minutes are spent face-to-face with the patient and/or family.
97163	Physical therapy evaluation: high complexity; typically, 45 minutes are spent face-to-face with the patient and/or family.
97164	Re-evaluation of physical therapy established plan of care; typically, 20 minutes are spent face-to-face with the patient and/or family.
97165	Occupational therapy evaluation, low complexity; typically, 30 minutes are spent face-to-face with the patient and/or family.

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Applicable HCPCS CodesHCPCSCovered

G0281	Electrical stimulation, unattended, to one or more areas, for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care.
S8948	Application of a modality requiring constant provider attendance to one or more areas; 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.

Authorization duration

Potential authorization periodUp to six months when authorized after clinical review

Review basisApplicable medical-necessity criteria

Practice standardIn accordance with generally accepted standards of practice

Re-evaluation interval

Required intervalAt least once every 6 months

More frequent reviewWhen required by state regulatory requirements

Authorization and Documentation Requirements

Prior Authorization

Clinical Review and Authorization

Requests are subject to applicable InterQual® LOC: Outpatient Rehabilitation & Chiropractic medical-necessity review. Documentation requirements below are used in addition to InterQual® and do not guarantee coverage; upon clinical review, UnitedHealthcare may authorize therapy for up to six months when appropriate and consistent with generally accepted standards of practice.

For maintenance therapy, refer to NMAC § 8.325.8: Specialty Services, Rehabilitation Service Providers.
For Alternative Benefit Package members age 21 and over receiving short-term rehabilitative therapy, refer to the Managed Care Policy Manual.

Documentation Required

Include the Plan of Care With Initial Authorization

The initial authorization submission must include an evaluation-based plan of care developed from the therapy evaluation results.

Policy Scope and Context

This policy addresses occupational, physical, and speech habilitation and rehabilitation therapy for New Mexico members. These services may be proven and medically necessary in certain circumstances when applicable medical-necessity criteria are met. Coverage determinations rely on the applicable InterQual LOC: Outpatient Rehabilitation & Chiropractic criteria, documented functional impairment, objective assessment, individualized measurable goals, progress toward those goals, and prognosis. Continued services also require current re-evaluation and an updated plan of care that supports ongoing need; maintenance therapy is addressed separately under applicable New Mexico administrative requirements.

Therapy Service Definitions

Habilitation and rehabilitation therapy

Policy definitionHabilitation and rehabilitation therapy is proven and medically necessary in certain circumstances, subject to applicable clinical coverage criteria

Therapy disciplinesOccupational, physical, and speech therapy

Rehabilitative focusServices may improve, adapt, or restore impaired or permanently lost functions, with goals achievable in a reasonable period with therapist or supervised therapy-assistant assistance

Maintenance therapy

DefinitionMaintenance therapy is supportive rather than corrective when further clinical improvement cannot reasonably be expected from continuous ongoing care

Applicable requirementRefer to New Mexico Administrative Code § 8.325.8: Specialty Services, Rehabilitation Service Providers

Policy Summary

PayerUnitedHealthcare Community Plan

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

Policy CodePolicy CS164NM.D

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionSubmit an evaluation-based plan of care with the initial authorization request, including the impairment, measurable goals, treatment frequency and duration, and anticipated session length.

SourceLink

On This Page

The updated plan of care or progress summary is not older than 90 days.not older than 90 days

When the majority of goals were not achieved

The updated plan of care describes the barriers to achievement.
The updated plan of care explains why goals were modified or discontinued.

The revised plan of care contains a meaningful update supporting the need for continued services; percentage accuracy toward goals alone is not sufficient to establish continued medical necessity.

ONE or more assessment outcomes

The characteristics of swallowing function and any breakdowns in swallow physiology are described.
A swallowing-disorder diagnosis is established.
The safest and most efficient route of nutrition and hydration intake, oral or nonoral, is determined.
The effectiveness of intervention and support is identified.
Recommendations are made for intervention and support for oral, pharyngeal, and/or laryngeal disorders.
The prognosis for improvement and other relevant factors, if appropriate, are documented.

Additional re-evaluation

Only when the individual experiences a significant change in functional level, condition, or functional status, with documentation reflective of the change

Updated plan of care

Maximum ageThe updated plan of care or progress summary must not be older than 90 days

Required contentUpdated measurable, functional, and time-based goals

Unmet goalsDocument barriers or explain why goals were modified or discontinued when the majority of long- and short-term goals were not achieved

Identify the functional or physical impairment.

Include short- and long-term therapeutic goals and objectives that are specific to the diagnosed condition or impairment, functional, measurable, attainable, time based, and related to individual-specific functional skills.

State treatment frequency and duration and the anticipated length of treatment sessions.

Documentation Required

Document the Initial Evaluation

The initial therapy evaluation report must establish the individual’s history, prior and current function, impairment, diagnosis, prognosis, and objective baseline findings.

Include medical history; comparison of prior level of function with current level of function, as applicable; and the functional impairment’s impact on health, safety, and/or independence.
Include a clear diagnosis with the appropriate ICD-10 code and a reasonable prognosis, including potential for meaningful and noteworthy progress.
Document baseline objective measurements and current deficits and severity using current standardized assessments or other appropriate objective information.

Documentation Required

Use Objective Assessment Alternatives When Needed

Use objective assessments that correspond to the identified delays and relate to the long- and short-term goals. Standardized assessment results cannot be the sole determinant of medical necessity for the initial therapy visit.

Report current standardized assessment scores, age equivalents, percentage of functional delay, criterion-referenced scores, and/or other appropriate objective information.
If a medical condition prevents standardized testing, provide in-depth objective clinical information using task analysis and include checklists, caregiver reports or interviews, and clinical observation.

Unsupported block type: documentation

Documentation Required

Complete Required Re-Evaluations

Complete a re-evaluation at least every six months, or more frequently when required by state regulation, to support ongoing services. More frequent re-evaluations should occur only after a significant change in functional level or status, and the documentation must reflect that change.

Include the date of the last therapy evaluation; authorized and attended visit counts; home-program adherence; current deficits and severity using objective data; and objective progress toward every treatment goal using consistent and comparable methods.
For unmet goals, document baseline and current function so progress can be measured.
Include current standardized assessment scores, percentage of functional delay, criterion-referenced scores, or other appropriate objective information; updated treatment modalities and frequency/duration; a brief prognosis; and clear discharge criteria.

Documentation Required

Update the Plan of Care

Submit an updated individualized plan of care or progress summary with the re-evaluation. The updated POC/progress summary must not be older than 90 days.

Updated goals must be measurable, functional, and time based.
If most long- and short-term goals were not achieved, explain barriers or why goals were modified or discontinued.

Documentation Required

Complete Treatment Session Notes

Each treatment session note must support the services billed and show skilled, objective progress toward the established goals.

Record the treatment date, specific treatments matching the CPT codes billed, and accurate treatment duration.
Document the individual’s response, skilled ongoing reassessment, and progress toward goals in objective, measurable terms using consistent and comparable methods.
Document problems with or changes to the POC; individual or caregiver involvement in and feedback about home-program activities; and the treating provider’s signature and date.

Documentation Required

Document Group Therapy

Group therapy documentation must establish that the service was ordered, individualized, supervised, and delivered for the documented duration and group setting.

Include the prescribing provider’s order and an individualized treatment plan with group-therapy frequency, duration, and individualized goals.
Record the supervising licensed therapist’s name and signature, specific treatment techniques and how they restore function, session length, group setting or location, and number of clients.

Documentation Required

Support Feeding and Swallowing Evaluations

Feeding and swallowing evaluation submissions must contain the clinical history, records, examination, prior testing, collaboration, assessment findings, and resulting clinical recommendations.

Include the interview/case history; medical and clinical records, including potential medication impact; physical examination; previous screening and assessments; and collaboration with providers and caregivers.
Document whether the individual is an appropriate candidate based on medical stability, cognitive, nutritional, psychosocial, environmental, and behavioral factors.
The assessment must describe swallowing function or breakdowns, diagnose a swallowing disorder, determine the safest and most efficient nutrition/hydration route, identify intervention effectiveness, provide intervention/support recommendations, and address prognosis or other relevant factors as applicable.

Documentation Required

Adapt Speech and Language Documentation

For individuals with limited English proficiency, use culturally and linguistically adapted norm-referenced standardized testing in every language to which the child is exposed and compare potential deficits appropriately.

Speech deficits and language deficits must be present in the language in which the individual has the highest proficiency.
Deliver services in the language of the individual’s highest receptive-language proficiency.
For dyslexia, include test results substantiating receptive or expressive language delay and goals addressing the corresponding deficits.

Billing Rule

Document Billed Evaluation, Re-evaluation, and Assessment Services

When billing evaluation, re-evaluation, or assessment services, retain documentation supporting the service components and the billed code, including the written report when required.

For occupational therapy re-evaluation, document changes in functional or medical status with a revised plan of care, update the occupational profile for changes affecting future interventions or goals, and provide the revised plan of care.
A formal re-evaluation requires a documented change in functional status or a significant change requiring the plan of care to be revised.
For assessment services, retain the required written report and documentation of the assessment, functional findings, interventions, and time or direct patient contact represented by the billed service.

Note

Cognitive Therapy Is Excluded

This policy does not apply to cognitive therapy. Direct outpatient cognitive therapy requests must be addressed under the separate UnitedHealthcare Medical Policy titled Cognitive Rehabilitation and Coma Stimulation (for New Mexico Only).

Refer outpatient cognitive therapy requests to the related cognitive rehabilitation policy.

Denial Risk

Provide a Meaningful Continued-Care Update

A revised POC that does not meaningfully update the clinical information supporting continued services will not be accepted. Percentage accuracy toward goals alone does not establish the need for continued medically necessary therapy.

Provide meaningful objective progress and current functional findings.
Explain barriers or goal changes when most goals were not achieved and document why continued skilled therapy remains needed.

Denial Risk

Medical Necessity Must Be Established

Coverage and continued services require applicable medical-necessity criteria and supporting documentation. Documentation requirements supplement InterQual® review and do not guarantee coverage.

Services may be denied or not continued when the applicable medical-necessity criteria are not established or the required evaluation, plan-of-care, re-evaluation, progress, or session documentation is insufficient.
Ensure records substantiate the requested service, functional impairment, measurable goals, objective progress, skilled need, and continued benefit.

Applicable disciplinesServices may include occupational, physical, or speech therapy

Rehabilitative services

PurposeServices intended to improve, adapt, or restore functions impaired or permanently lost

Qualifying circumstancesImpairment or loss resulting from illness, injury, loss of a body part, or congenital abnormality

Goal standardGoals must be achievable in a reasonable period with assistance from a therapist or a therapy assistant under a therapist’s supervision

Habilitation services

DefinitionHealth care services that help a person keep, learn, or improve skills and function for daily living

ExampleTherapy for a child who is not walking or talking at the expected age

Services may includePhysical and occupational therapy, speech-language pathology, and other services for individuals with disabilities

Maintenance therapy

PurposeServices intended to prevent disease, promote health, prolong or enhance quality of life, or maintain function or prevent deterioration of a chronic condition

When applicableWhen further clinical improvement cannot reasonably be expected from continuous ongoing care

Treatment characterSupportive rather than corrective; services may include occupational, physical, or speech therapy