CurrentUnitedHealthcarePolicy BIP147.R

Rehabilitation Services (Physical, Occupational, and Speech Therapy)

Defines coverage, medical necessity criteria, covered settings, examples of covered therapies, and exclusions for physical, occupational, and speech therapy for UnitedHealthcare West (California) members, referencing federal/state mandated regulations and related medical policies.

Policy Summary

PayerUnitedHealthcare

PolicyRehabilitation Services (Physical, Occupational, and Speech Therapy)

Policy CodePolicy BIP147.R

Change TypeRevisions and additions to coverage and exclusions

Effective DateSep 1, 2025

Next Review Date

Key ActionDocument relevant medical history, rehabilitation potential, prior level of function, exam and diagnostic results, ongoing assessments and plan adjustments, measurable individualized goals, and weekly progress reviews including objective measures (e.g., FIM scores) and clinical narrative.

SourceLink

POLICY UPDATE CHANGES

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

Added language to indicate coverage is provided for physical and occupational therapy provided in an organized, multidisciplinary rehabilitation day-treatment program, a skilled nursing facility, and in an inpatient hospital (including treatment in an 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; removed 'fluidized therapy (fluidotherapy)' from examples.

Added list of explicitly not covered services including vocational/prevocational training solely for employment, PNT/PENS, sensory integration therapy, coordination therapy, gym memberships, and other non-medical services.

Updated References section to reflect most current information.

3Minimum therapies required for inpatient multidisciplinary team

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3 hrs/dayMinimum daily therapy intensity for inpatient rehab

5 days/weekMinimum weekly therapy frequency for inpatient rehab

20+Examples of not-covered service types listed

Coverage Summary

This policy aligns UnitedHealthcare coverage with California statutory and regulatory requirements for rehabilitative and habilitative services and defines coverage, medical necessity criteria, covered settings, examples of covered therapies, and specific exclusions for physical, occupational, and speech therapy. Effective date: 2025-09-01; Last review: 2025-09-01. Coverage stance: mixed.

Acute inpatient rehabilitation medical necessity requires coordinated multidisciplinary care (minimum disciplines and intensity thresholds described in the referenced criteria) and documentation of rehabilitation potential, individualized measurable goals, and weekly progress reviews. Detailed clinical medical necessity criteria and operational specifics are provided in the referenced Medical Policy titled Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech).

Surface thresholds and quick facts

Minimum daily therapy intensityMinimum of 3 hours per day

Minimum weekly frequencyAt least 5 days per week

Minimum therapies required (multidisciplinary team)Requires treatment from at least two therapies (e.g., PT, OT, ST); stats list shows minimum of 3 therapies for inpatient multidisciplinary team

Medical Necessity Criteria

Acute Inpatient Rehabilitation - Medical Necessity

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

ALL of the following

The member requires treatment from a multidisciplinary team consisting of at least two therapies (e.g., physical therapy, occupational therapy, speech therapy).
The member is stable enough medically and is capable and willing to participate in intensive therapy for a minimum of three hours per day, at least five days per week.minimum of 3 hours per day, at least 5 days per week
The rehabilitation program is expected to result in significant therapeutic improvement over a clearly defined period of time.

Not Covered Services and Explicit Exclusions

Not Covered Services

The following services are not covered:

ANY of the following

Inpatient rehabilitation solely for the purpose of providing cognitive rehabilitation therapy 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 except when part of a physical therapy treatment plan and covered under inpatient hospital, outpatient hospital, outpatient services or unless mandated by state or federal law and/or market plan enhancements
Services considered investigational or experimental by UnitedHealthcare
Speech, occupational, or physical therapy when the member has either attained therapy treatment plan goals or is unable to attain the treatment plan goals

Provider Actions & Documentation Requirements

Documentation Required

Medical record documentation required for inpatient rehab medical necessity

Document relevant medical history, rehabilitation potential, prior level of function, physical examination, results of pertinent diagnostic tests or procedures, ongoing assessment and necessary adjustments to the plan of care, current functional status and measurable individualized goals, and weekly progress reviews including objective measures (e.g., FIM scores) and a clinical narrative demonstrating functional improvement and progress toward treatment goals.

Relevant medical history
Rehabilitation potential
Prior level of function
Physical examination
Results of pertinent diagnostic tests or procedures
Ongoing assessments and adjustments to plan of care
Current functional status
Measurable individualized goals
Weekly progress reviews including objective measures (e.g., FIM scores) and clinical narrative

Referenced Policies and Regulations (Informational)

Referenced policies and external regulations (informational)mixed

California Health & Safety Code Section 1367.005

Statute requiring coverage of basic health care services including rehabilitative and habilitative services as part of plan benefits, specifying physician, inpatient hospital, ambulatory care, and home health services including physical, occupational, and speech therapy when medically necessary.

California Code of Regulations Section 1300.67.005

Regulation requiring health plans offering contracts subject to Health and Safety Code Section 1367.005 to file Essential Health Benefits information, and specifying coverage requirements for rehabilitative/habilitative services including individual and group outpatient therapy, therapy in multidisciplinary day-treatment programs, skilled nursing facilities, and inpatient hospitals; also requires disclosure that limits for rehabilitative and habilitative services shall not be combined.

Detailed coding (CPT/HCPCS) and billing specifics are not listed here and are deferred to the referenced Medical Policy titled Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech), which contains applicable criteria and operational details for coverage and claim submission.

Background

This policy reflects alignment with California statutory and regulatory requirements (e.g., Health and Safety Code and implementing regulations) for rehabilitative and habilitative services and clarifies covered settings (such as comprehensive outpatient rehabilitation facilities, physician or therapist offices, member's residence, hospitals, organized multidisciplinary rehabilitation day-treatment programs, skilled nursing facilities, and inpatient hospitals), provider qualifications (licensed physicians, licensed therapy providers, qualified autism service providers, or others authorized under California law), examples of covered therapies (e.g., therapeutic exercises, gait training, diathermy, aquatic therapy when part of an authorized plan), and enumerated exclusions. Detailed clinical medical necessity criteria and operational requirements are provided in the referenced Medical Policy titled Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech).

Definitions

Acute Inpatient Rehabilitation (definition)An intense multidisciplinary service to restore or enhance function post injury or illness, requiring coordinated therapy from at least two therapy disciplines and meeting specified intensity and documentation criteria.

Medicare Determinations

Name	Type	Effective/Accessed
Skilled Nursing Facility, Rehabilitation, and Long-Term Acute Care Hospital Coverage Summary	informational	Accessed 2025-06-16

Revision History

2025-09-01revised

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

2025-09-01revised

Policy Summary

PayerUnitedHealthcare

PolicyRehabilitation Services (Physical, Occupational, and Speech Therapy)

Policy CodePolicy BIP147.R

Change TypeRevisions and additions to coverage and exclusions

Effective DateSep 1, 2025

Next Review Date

SourceLink

On This Page

The rehabilitation program is individualized, and documentation outlines quantifiable, attainable treatment goals.

Rehabilitation is required in an inpatient rehabilitation facility rather than a less intense setting. Rehabilitative care services are determined by the member's functional needs and the availability of resources.

Documentation in the member's medical record must support medical necessity and include relevant medical history, rehabilitation potential and prior level of function, physical examination, results of pertinent diagnostic tests or procedures, ongoing assessment and adjustments to the plan of care, current functional status and measurable individualized goals, and weekly progress reviews including objective measurements (e.g., FIM scores) and clinical narrative demonstrating functional improvement.

Services consist of 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 a healthcare professional under the direct supervision of a licensed physical therapist acting within the scope of his or her license under California law.

Examples of Covered Physical and Occupational Therapies

Included therapies (not an exhaustive list):

ANY of the following

Ultrasound, shortwave, and microwave diathermy treatments
Range of motion tests
Gait training
Therapeutic exercises
Aquatic/pool therapy, only as part of an authorized treatment plan provided by a licensed physical therapist with the therapist in attendance
therapist must be in attendance
Recreational therapy services only when authorized, part of a medically necessary treatment plan, provided by an authorized provider who is a registered physical, speech, or occupational therapist or a health care professional under supervision of a licensed physical therapist acting within the scope of his or her license or as authorized under California law

Vocational, prevocational, and educational assessment and training related solely to specific employment opportunities, work skills, or work settings

Percutaneous neuromodulation therapy (PNT) / percutaneous electrical nerve stimulation (PENS) for the treatment of pain, as part of physical therapy or in the doctor's office

Sensory integration therapy

Coordination therapy

Attention deficit hyperactivity disorder services (as listed in changes section)

Dyslexia services (as listed in changes section)

Services that are considered custodial

Programs that do not require the supervision of a physician and/or licensed therapy provider

Gym and fitness club memberships and fees, health club fees, exercise equipment or supplies

Physiological modalities and procedures that result in similar or redundant therapeutic effects when performed on the same body region during the same visit or office encounter

Hypnotherapy/hypnotic services

Motivational or social activities/therapy

Note: This policy was revised to clarify regulatory citations and coverage language and to add or explicitly list exclusions and clarified items — including vocational/prevocational exclusions, percutaneous neuromodulation therapy (PNT/PENS), and sensory integration therapy. For complete and detailed clinical criteria and operational guidance, refer to the Medical Policy titled Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech).

Documentation Required

Therapist/provider qualifications

Ensure therapy services are performed by physicians, licensed therapy providers, qualified autism service providers, or other providers licensed, certified, or otherwise authorized under California law and acting within their scope of practice, or by healthcare professionals under appropriate supervision per California law.

Physician
Registered physical therapist
Registered occupational therapist
Registered speech therapist
Qualified autism service provider
Other providers licensed/certified/authorized under California law
Healthcare professionals under direct supervision of a licensed physical therapist acting within scope of license

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

2025-09-01revised

Revised list of examples of covered physical and occupational therapies; removed 'fluidized therapy (fluidotherapy)' from examples.

2025-09-01removed

Removed definitions for Occupational Therapy and Physical Therapy.

2025-09-01added

2025-09-01updatedLatest

Updated References section to reflect most current information.