Clinical UM Guideline

This document addresses physical therapy, occupational therapy, and speech-language pathology services, also called speech therapy services, provided in the home setting.

Rehabilitative services are intended to improve, adapt or restore functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality involving goals an individual can reach in a reasonable period of time. Benefits will end when treatment is no longer medically necessary and the individual stops progressing toward those goals.

Habilitative services are intended to maintain, develop or improve skills needed to perform activities of daily living (ADLs) or instrumental activities of daily living (IADLs) (see definitions) which have not (but normally would have) developed or which are at risk of being lost as a result of illness, injury, loss of a body part, or congenital abnormality. An example is therapy for a child who is not walking at the expected age.

Note: The availability of rehabilitative and/or habilitative benefits for these services, state and federal mandates, and regulatory requirements should be verified prior to application of criteria listed below. Benefit plans may include a maximum allowable physical, occupational, or speech therapy benefit, either in duration of treatment or in number of visits. When the maximum allowable benefit is exhausted, coverage will no longer be provided even if the medical necessity criteria described below are met.

Note: For criteria of physical therapy, occupational therapy, or speech-language pathology services in the home setting, refer to applicable guidelines used by the plan. Benefits, state mandates and regulatory requirements should be verified prior to application of criteria listed below. The criteria for these services may vary by plan due to state or Centers for Medicare and Medicaid services (CMS) requirements.

Note: Please see the following related document for additional information related to home health care services:

• CG-MED-23 Home Health

Medically Necessary:

Physical therapy, occupational therapy, or speech-language pathology services in the home setting are considered medically necessary when both of the criteria below are met:

1. The individual’s therapy request meets medical necessity criteria under the physical, occupational, or speech-language pathology guidelines used by the plan; and
2. The request meets medical necessity criteria for home health care outlined in CG-MED-23 Home Health.

Not Medically Necessary:

Physical therapy, occupational therapy, or speech-language pathology services in the home setting are considered not medically necessary when the above criteria are not met.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.