CurrentUnitedHealthcarePolicy BIP147.R

Rehabilitation Services (Physical, Occupational, and Speech Therapy)

Defines UnitedHealthcare coverage, settings, and high-level medical necessity criteria for physical, occupational, and speech therapy services for members, with references to applicable California state regulations and related medical policies; affects providers delivering rehab services in California.

Policy Summary

PayerUnitedHealthcare

PolicyRehabilitation Services (Physical, Occupational, and Speech Therapy)

Policy CodePolicy BIP147.R

Change TypeMaterial revisions and additions (state regulatory languagecoverage setting additionsreferral to related medical policy)

Effective DateSeptember 1, 2025

Next Review DateN/A

Key ActionObtain and document multidisciplinary team assessment, therapy intensity (minimum 3 hours/day, 5 days/week), measurable goals, and refer to the Habilitation and Rehabilitation Therapy medical policy for detailed authorization criteria.

SourceLink

POLICY UPDATE CHANGES

Revised language pertaining to California Health and Safety Code Section 1300.67 and California Code of Regulations Section 1300.67.005.

Added language indicating coverage is provided for physical and occupational therapy in an organized, multidisciplinary rehabilitation day-treatment program, skilled nursing facility, and inpatient hospital (including organized multidisciplinary rehabilitation program).

Replaced coverage criteria with instruction to refer to the Medical Policy titled Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) for applicable details.

Revised list of examples of covered physical and occupational therapies and removed fluidized therapy from examples.

3 hrs/dayMin therapy time

5 days/weekMin frequency

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Coverage Criteria for Rehabilitation Services

Acute Inpatient Rehabilitation

Covered when ALL of the following are met:

Acute inpatient rehabilitation medical necessity criteria: The member requires treatment from a multidisciplinary team consisting of at least two therapies (e.g., physical therapy, occupational therapy, speech therapy).

Ability to participate: The member is medically stable and is capable and willing to participate in intensive therapy for a minimum of three hours per day, at least five days per week.3 hours/day, 5 days/week

Documentation must support the ability and willingness to participate

Expectation of improvement: The rehabilitation program is expected to result in significant therapeutic improvement over a clearly defined period of time.

Individualized plan and goals: The rehabilitation program is individualized with documentation that outlines quantifiable, attainable treatment goals.

Current functional status and measurable goals must be part of the plan of care; progress toward goals should be reviewed at least weekly with objective measurements (e.g., FIM scores) and clinical narrative.

Setting appropriateness: Rehabilitation is required in an inpatient rehabilitation facility rather than a less intense setting; rehabilitative care is determined by the member's functional needs and available resources.

Documentation must demonstrate that inpatient level of care is necessary

Provider qualifications and coordination: Care consists of the combined and coordinated use of physical, occupational, and speech therapy provided by network providers who are registered therapists or by healthcare professionals under the direct supervision of a licensed physical therapist acting within the scope of California law.

Covered Settings

Covered settings and referral:

Covered settings: Physical and occupational therapy provided in an organized, multidisciplinary rehabilitation day-treatment program; in a skilled nursing facility; and in an inpatient hospital (including treatment in an organized multidisciplinary rehabilitation program).

Refer to the Medical Policy titled Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) for detailed criteria

Speech therapy setting: Speech therapy provided in an organized, multidisciplinary rehabilitation day-treatment program; in a skilled nursing facility; and in an inpatient hospital (including treatment in an organized multidisciplinary rehabilitation program).

Refer to the Medical Policy titled Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) for detailed criteria

Provider qualifications: Therapy services must be performed by a physician, a licensed therapy provider, a qualified autism service provider, or other providers licensed, certified or otherwise authorized under California state law to perform the service and within the provider's scope of practice.

The policy does not cover inpatient rehabilitation solely for cognitive rehabilitation when the member’s underlying medical condition does not otherwise meet criteria for inpatient intensive skilled services such as rehabilitation nursing, physical therapy, occupational therapy, or speech therapy. Examples include admissions where cognitive retraining is the only anticipated skilled intervention and the member would not otherwise require an inpatient level of rehabilitative care.

Additionally, massage therapy is not covered except when it is an element of an authorized physical therapy treatment plan and billed under the appropriate inpatient or outpatient hospital or outpatient services, or when coverage is required by state or federal law or specific market plan enhancements.

Services deemed investigational or experimental are excluded from coverage under this policy.

Therapy services (speech, occupational, or physical therapy) are not covered when the member has attained the therapy treatment plan goals or is unable to attain the treatment plan goals. In such situations, continuation of skilled therapy is not considered medically necessary and should be discontinued.

Use measurable, individualized treatment goals and ongoing assessments to demonstrate continued progress and rehabilitation potential; absence of progress toward those goals or clear inability to participate/benefit supports discharge rather than continued therapy.

Coding and Intensity Metrics

Covered CPT Codesmixed

No codes listed

Intensive Therapy Minimum — inv-06

Minimum intensityMinimum of 3 hours per day, at least 5 days per week

Multidisciplinary requirementTreatment from a multidisciplinary team consisting of at least two therapies (e.g., PT, OT, ST)

Medical stability and participationMember must be medically stable and capable/willing to participate in intensive therapy

Documentation of progressProgress toward goals must be reviewed at least weekly with objective measurements (e.g., FIM scores) and clinical narrative

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization and Coverage Directive — Acute Inpatient Rehabilitation

Prior authorization is required for acute inpatient rehabilitation. Documentation must demonstrate that the member meets multidisciplinary team, intensity, and measurable improvement criteria (see required documentation below). Verify member-specific coverage limits and any benefit edits in the member's Evidence of Coverage (EOC) / Schedule of Benefits (SOB) or applicable Speech Therapy Amendment before submitting an authorization request.

Acute inpatient rehabilitation requires multidisciplinary team care and intensive therapy (minimum ~3 hours/day, ≥5 days/week).
Prior authorization requests should include clinical justification tying the need for an inpatient rehabilitation facility to the member's functional needs, demonstrating that care cannot be provided in a less intensive setting.

Note

EOC/SOB Governs Member-Specific Limits

Refer to the member's Evidence of Coverage (EOC) / Schedule of Benefits (SOB) or Speech Therapy Amendment for member-specific coverage, benefit limits, visit/day limits, and any plan-level exclusions or prior authorization requirements. The EOC/SOB governs applicability of limits and member financial responsibility.

Background and Scope

Acute inpatient rehabilitation provides an organized, multidisciplinary approach to restore or enhance function after illness or injury. The purpose is to deliver intensive, skilled therapies—typically including at least two therapy disciplines—so that the member can achieve quantifiable, attainable treatment goals in an inpatient setting rather than a less intensive setting.

Programs are individualized and require documentation of medical necessity, including the member’s ability to participate in intensive therapy and expected significant therapeutic improvement over a defined period. Services that do not meet the criteria for intensive inpatient rehabilitation (for example, admissions only for cognitive rehabilitation when other inpatient skilled-service criteria are not met) are not covered.

Definitions

Acute Inpatient Rehabilitation — inv-12

DefinitionAcute inpatient rehabilitation is an individualized, intensive inpatient program providing combined and coordinated physical, occupational, and speech therapy by qualified network providers

Team compositionRequires treatment from a multidisciplinary team consisting of at least two therapies (e.g., physical, occupational, speech)

Setting requirementRehabilitation is required in an inpatient rehabilitation facility rather than a less intense setting

Program attributesProgram is individualized with quantifiable, attainable treatment goals and expected significant therapeutic improvement over a defined period

Documentation expectationsMedical record must document medical history, rehabilitation potential, prior level of function, physical exam, diagnostic results, ongoing assessment, and weekly progress reviews