Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Pennsylvania Only)
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Policy governing medical necessity, documentation, and authorization requirements for outpatient habilitation and rehabilitation therapy (OT, PT, and ST) for UnitedHealthcare Community Plan members in Pennsylvania.
Updated list of required documentation for a therapy re-evaluation report; replaced 'compliance to home program' with 'adherence to home program'.
Updated reference link to the Pennsylvania Code § 55.1101.31(f): Exceptions.
Updated Clinical Evidence and References sections to reflect the most current information.
Coverage Criteria and Medical Necessity
Medical Necessity (InterQual-based)
Covered when InterQual LOC criteria for outpatient rehabilitation are met and documentation requirements are satisfied.
UnitedHealthcare may authorize therapies based on InterQual criteria for up to six months when appropriate.
Initial, Continued, and Re-evaluation Criteria
Documentation and utilization requirements for initial, continuation, and re-evaluation authorizations.
Standardized assessments must correspond to identified delays; alternatives allowed if testing not possible.
The updated POC/progress summary must not be older than 90 days. A revised POC stating no meaningful update will not be accepted; percentage toward goals alone is insufficient to support continued services.
General medical necessity
Covered when services meet rehabilitative or habilitative intent and are reasonable and necessary
Definitions of rehabilitative, habilitative, and maintenance therapy are in the policy.
Modality-specific coverage notes
Specific modalities and situations
Services that are maintenance in nature (e.g., S8990) may be excluded or subject to different coverage rules depending on benefit terms.
Per HCPCS descriptors and policy thresholds for wound electrical stimulation.
This policy does not apply to cognitive therapy. For outpatient cognitive therapy services, refer to the separate UnitedHealthcare policy titled Cognitive Rehabilitation and Coma Stimulation (for Pennsylvania Only).
Services that are performed solely for maintenance rather than restoration (reported with HCPCS S8990) are distinguished from rehabilitative services and may be excluded or subject to different coverage rules depending on benefit terms.
Procedures that are supportive in nature without a reasonable expectation of further clinical improvement are treated as maintenance and not rehabilitative; such supportive services should be clearly identified in documentation and may not meet medical necessity for ongoing restorative therapy.
Services are considered not medically necessary when the skill of a therapist is not required to provide the service, when documented treatment goals and objectives have been met, when functional abilities are comparable to peers of the same chronological age, or when the individual/family declines participation or relocates making continued services impractical.
Additional examples include situations where the desired level of function agreed to by the individual and provider has been achieved, the individual exhibits behavior that prevents improvement despite attempts to address it, or a transfer/discharge makes continuation of services from the current provider unreasonable.
Maintenance therapy is defined as services provided to prevent disease progression or maintain function when further clinical improvement cannot reasonably be expected and the treatment is primarily supportive rather than corrective.
When therapy is maintenance in nature—i.e., ongoing care is unlikely to produce additional functional gains—the service is considered supportive and may not meet the medical necessity requirements for rehabilitative coverage.
Applicable Procedure and HCPCS Codes
| 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 (e.g., articulation, phonological process, apraxia, dysarthria); 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. |
| 97012 | Application of a modality to 1 or more areas; traction, mechanical. |
| 97024 | Application of a modality to 1 or more areas; diathermy (e.g., microwave). |
| 97026 | Application of a modality to 1 or more areas; infrared. |
| 97028 | Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. |
| 97032 | Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes / iontophoresis, each 15 minutes. |
| 97033 | Application of a modality to 1 or more areas; iontophoresis, each 15 minutes / contrast baths, each 15 minutes. |
| 97034 | Application of a modality to 1 or more areas; contrast baths, each 15 minutes. |
| 97035 | Application of a modality to 1 or more areas; ultrasound, each 15 minutes. |
| 97036 | Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes. |
| 97039 | Unlisted modality (specify type and time if constant attendance). |
| 97110 | Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. |
Provider Requirements, Prior Authorization, and Documentation
Obtain and Maintain a Referring Provider Order Before Initial Evaluation
A referring provider order (PCP or appropriate specialist: MD, DO, PA, or NP) must be on file prior to completion of the initial therapy evaluation unless the state exempts this requirement. UnitedHealthcare may authorize therapies based on InterQual medical necessity criteria for up to six months when appropriate.
- Referral/order must be from PCP (MD, DO, PA, NP) or appropriate specialist
- State exemptions to the referral requirement apply
- Authorizations may be issued up to six months per clinical review and standards of practice
Verify Prior Authorization for Listed CPT/HCPCS Codes
Prior authorization rules apply to the therapy services listed in the policy; providers should verify benefit-specific prior authorization requirements for the CPT and HCPCS codes enumerated in the policy.
Ensure Services Are Distinct and Non‑Duplicative
Therapy services must not duplicate services provided concurrently by another therapy type and must demonstrate different treatment goals, plans, and therapeutic modalities.
- Ensure documented goals and POC clearly distinguish the therapy from concurrent PT/OT/ST services
- Avoid billing overlapping services that provide the same therapeutic intent
Expect Use of InterQual and Other External Criteria Tools
UnitedHealthcare may use third-party tools, such as the InterQual criteria, to assist in administering benefits and determining coverage pathways for outpatient rehabilitation services.
- InterQual LOC: Outpatient Rehabilitation & Chiropractic criteria is referenced for medical necessity determinations
- Use of third‑party tools supplements but does not replace required documentation
Include Required Elements in the Initial Evaluation and Plan of Care
The initial therapy evaluation report must include the individual's medical history; comparison of prior and current function; a description of the functional impairment and its impact on health, safety, or independence; a clear diagnosis with ICD-10 code; prognosis; baseline objective measurements; and a plan of care with measurable goals, frequency/duration, and anticipated session length.
- Medical history and comparison of prior vs current function
- Functional impairment description and ICD‑10 diagnosis with prognosis
- Baseline objective measures (standardized assessments or task analysis) and POC with measurable short‑ and long‑term goals, frequency/duration, and session length
Document Required Elements in Re-evaluation Reports (Adherence to Home Program)
Re-evaluation reports must contain the required documentation elements and, per recent wording update, must document 'adherence to home program' along with objective data on deficits, progress toward goals, date of last evaluation, visits authorized/attended, and an updated plan of care including discharge criteria and prognosis.
- Document date of last evaluation and number of visits authorized/attended
- Include objective measures of progress and updated POC with discharge criteria
- Document adherence to home program (replaces prior wording 'compliance to home program')
Denial Risk if Documentation Is Incomplete or Does Not Meet Medical Necessity
Requests may be denied if documentation does not meet InterQual medical necessity criteria or if the evaluation, plan of care, or treatment session notes are incomplete or fail to demonstrate need for skilled services.
- Ensure treatment notes document date, services matching billed CPT codes, session length, response to treatment, objective progress, POC changes, and therapist signature/date
- Documentation must demonstrate ongoing skilled reassessment and objective progress toward measurable goals
Maintenance Therapy May Not Be Covered
Services that are maintenance in nature—where further clinical improvement cannot reasonably be expected and treatment is supportive rather than corrective—may not meet rehabilitative medical necessity and could be noncovered.
- Maintenance services are exemplified by HCPCS S8990 (maintenance rather than restoration)
- Confirm that POC demonstrates restorative intent and measurable goals to avoid maintenance designation
Key Definitions
Background and Scope
Habilitation, rehabilitation, and maintenance therapies may be medically necessary in certain circumstances when services meet rehabilitative or habilitative intent and are reasonable and necessary.
UnitedHealthcare uses external clinical criteria such as InterQual® LOC: Outpatient Rehabilitation & Chiropractic to guide determinations of medical necessity for outpatient occupational, physical, and speech therapy, and may authorize services in accordance with those criteria.
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