Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesPhysical Medicine, Rehab & TherapiesUnitedHealthcare Rehab Therapy Coverage | OpenPaye…
    Ask Trek AI about this page
    ModifiedUnitedHealthcarePolicy BIP147.S

    Rehabilitation Services (Physical, Occupational, and Speech Therapy)

    Customize your policy alerts

    Sign up for UnitedHealthcare Policy BIP147.S alerts

    Get alerted when Policy BIP147.S changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Coverage and medical-necessity requirements for physical, occupational, and speech therapy services for UnitedHealthcare of California HMO and Benefits Plan of California EPO/POS members, including acute inpatient rehabilitation and non-covered services.

    Policy Summary
    PayerUnitedHealthcare
    PolicyRehabilitation Services (Physical, Occupational, and Speech Therapy)
    Policy CodePolicy BIP147.S
    Change TypeModified
    Effective DateSeptember 1, 2026
    Next Review DateN/A
    Key ActionDocument medical history, rehabilitation potential, functional status, measurable goals, ongoing assessment, and weekly objective progress toward goals.
    SourceLink
    POLICY UPDATE CHANGES

    Federal and state mandated regulation language was revised for California Health and Safety Code Section 1300.67.

    The covered-benefits examples for physical and occupational therapies were revised.

    The prior covered-benefits language for recreational therapy services was removed.

    The not-covered list now expressly includes activities that are solely recreational, social, or for general fitness, such as gyms and dancing classes.

    The list of non-covered services was revised.

    Language pertaining to California Health and Safety Code Section 1300.67 was revised.

    The list of examples of physical and occupational therapies was revised.

    The prior language allowing certain recreational therapy services under specified authorization, treatment-plan, provider, and supervision conditions was removed from the covered-benefit provisions.

    Activities solely recreational, social, or for general fitness, including gyms and dancing classes, were added to the list of non-covered services.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    3 hours/day, 5 days/weekAcute inpatient rehabilitation intensity
    At least 2Required therapy disciplines
    WeeklyProgress review frequency
    5Non-covered service categories
    CAState-specific scope

    Coverage Criteria

    Acute Inpatient Rehabilitation

    Acute inpatient rehabilitation is medically necessary when all of the following criteria are met:

    Acute inpatient rehabilitation medical necessity

    • Multidisciplinary treatment: The member requires treatment from a multidisciplinary team consisting of at least two therapies, such as physical therapy, occupational therapy, or speech therapy.At least 2 therapies
    • Intensity and participation: The member is medically stable enough and is capable and willing to participate in intensive therapy.Minimum 3 hours per day, at least 5 days per week
    • Expected improvement: The rehabilitation program is expected to result in significant therapeutic improvement over a clearly defined period of time.
    • Individualized goals: The rehabilitation program is individualized, and documentation outlines quantifiable and attainable treatment goals.
    • Inpatient level of care: Rehabilitation is required in an inpatient rehabilitation facility rather than a less intense setting, based on the member's functional needs and the availability of resources.
    • Qualified and coordinated delivery: The program consists of the combined and coordinated use of physical, occupational, and speech therapy provided by a network provider who is a registered physical, speech, or occupational therapist, or by a healthcare professional under the direct supervision of a licensed physical therapist acting within the scope of the license under California law.

    General Coverage Requirements

    Covered benefits are organized under federal/state mandated regulations, state market plan enhancements, and covered benefits. All services must be medically necessary:

    General coverage requirements: The rehabilitation service must be medically necessary and covered under the applicable member Evidence of Coverage or Schedule of Benefits.

    Each benefit plan contains specific provisions for coverage, limitations, and exclusions. If this policy conflicts with the member's Evidence of Coverage or Schedule of Benefits, the member's plan document governs.

    Solely recreational, social, or general-fitness activities are not covered, including gym activities and dancing classes.

    Inpatient rehabilitation provided solely for cognitive rehabilitation is not covered when treatment of the member’s medical condition does not otherwise meet criteria for inpatient intensive skilled rehabilitation nursing care, physical therapy, occupational therapy, or speech therapy services.

    Massage therapy is not covered unless it is part of a physical therapy treatment plan and covered under inpatient hospital, outpatient hospital, or outpatient services, or unless mandated by state or federal law or market plan enhancements.

    Services considered investigational or experimental by UnitedHealthcare are not covered.

    Speech, occupational, or physical therapy is not covered after the member has attained the treatment-plan goals or is unable to attain those goals.

    Solely recreational, social, or general-fitness activities are non-covered services, including gym activities and dancing classes.

    Inpatient rehabilitation provided solely for cognitive rehabilitation is not medically necessary when the member’s condition does not otherwise meet criteria for inpatient intensive skilled rehabilitation nursing care, physical therapy, occupational therapy, or speech therapy services.

    Continued speech, occupational, or physical therapy is not medically necessary after the member has attained the treatment-plan goals or is unable to attain those goals.

    Documentation and Denial Risks

    Documentation Required

    Acute Inpatient Rehabilitation Documentation

    Maintain a complete medical record supporting acute inpatient rehabilitation, including the member’s relevant medical history, rehabilitation potential, prior level of function, physical examination, and pertinent diagnostic test or procedure results. The record must document ongoing assessment and necessary adjustments to the plan of care, current functional status, individualized measurable goals, and progress toward those goals at least weekly.

    • Include objective measurements, such as FIM scores, together with a clinical narrative demonstrating functional improvement and progress toward attainable treatment goals resulting from the therapy provided.
    • Document the combined and coordinated use of at least two therapies—physical, occupational, and/or speech therapy—provided by a network provider who is a registered therapist or by a healthcare professional under the direct supervision of a licensed physical therapist acting within the scope of the license under California law.
    Documentation Required

    Support Medical Necessity for Inpatient Level of Care

    Support the inpatient level of care with individualized, quantifiable, and attainable rehabilitation goals and documentation showing that inpatient rehabilitation is required rather than a less intense setting. Acute inpatient rehabilitation is medically necessary only when the member’s condition and expected benefit support intensive multidisciplinary treatment.

    Acute Inpatient Rehabilitation Overview

    Acute inpatient rehabilitation is an intensive multidisciplinary service intended to restore or enhance function after injury or illness. It is designed for medically stable members who are able and willing to participate in intensive therapy, with an individualized program expected to produce significant therapeutic improvement over a defined period.

    Key Definitions

    Acute inpatient rehabilitation
    DefinitionAn intense multidisciplinary rehabilitation service intended to restore or enhance function after injury or illness.
    Multidisciplinary careTreatment requires a multidisciplinary team consisting of at least two therapies, such as physical therapy, occupational therapy, or speech therapy.
    Participation intensityThe member must be medically stable, capable, and willing to participate in intensive therapy for a minimum of 3 hours per day, at least 5 days per week.
    Expected outcomeThe rehabilitation program must be expected to result in significant therapeutic improvement over a clearly defined period of time.
    Inpatient level of careRehabilitation must be required in an inpatient rehabilitation facility rather than a less intense setting, based on the member's functional needs and available resources.
    Policy Summary
    PayerUnitedHealthcare
    PolicyRehabilitation Services (Physical, Occupational, and Speech Therapy)
    Policy CodePolicy BIP147.S
    Change TypeModified
    Effective DateSeptember 1, 2026
    Next Review DateN/A
    Key ActionDocument medical history, rehabilitation potential, functional status, measurable goals, ongoing assessment, and weekly objective progress toward goals.
    SourceLink
    On This Page
    Coverage CriteriaDocumentation and Denial RisksAcute Inpatient Rehabilitation OverviewKey Definitions
    • Document participation in a multidisciplinary team involving at least two therapies, such as physical therapy, occupational therapy, and/or speech therapy.
    • Document that the member is medically stable and capable and willing to participate in intensive therapy for at least three hours per day, at least five days per week.
    • Show that the program is expected to produce significant therapeutic improvement over a clearly defined period of time.
    • Support the member’s need for inpatient rehabilitation based on functional needs and available resources, rather than a lower-intensity setting.
    Denial Risk

    Non-Covered Services and Failed Therapy Goals

    Avoid billing services that fall within UnitedHealthcare’s non-covered categories or continuing therapy after the treatment plan is complete or goals cannot be attained.

    • Solely recreational, social, or general-fitness activities, including gyms and dancing classes, are not covered.
    • Inpatient rehabilitation solely for cognitive rehabilitation is not covered when the member’s medical condition does not otherwise meet criteria for inpatient intensive skilled rehabilitation nursing care, physical therapy, occupational therapy, or speech therapy services.
    • Massage therapy is not covered except when it is part of a physical therapy treatment plan and covered under inpatient hospital, outpatient hospital, or outpatient services, or when mandated by state or federal law or included through market plan enhancements.
    • Services considered investigational or experimental by UnitedHealthcare are not covered.
    • Speech, occupational, or physical therapy is not covered when the member has attained the treatment-plan goals or is unable to attain them.
    Denial Risk

    Medical Necessity and Plan Provisions

    All services must be medically necessary and must comply with the member’s applicable benefit-plan provisions. Coverage may be denied when services conflict with the Evidence of Coverage or Schedule of Benefits.

    • Review the applicable Federal/State Mandated Regulations, State Market Plan Enhancements, and Covered Benefits provisions.
    • If this policy conflicts with the member’s Evidence of Coverage or Schedule of Benefits, the member’s Evidence of Coverage or Schedule of Benefits provision governs.
    • Confirm coverage, limitations, and exclusions under the member’s specific benefit plan before providing or billing services.