Rehabilitation Services (Physical, Occupational, and Speech Therapy): OK, OR, TX, WA – UnitedHealthcare West Benefit Interpretation Policy

Rehabilitation Services (Physical, Occupational, and Speech Therapy)

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UnitedHealthcare West Benefit Interpretation Policy

Effective 06/01/2024

UnitedHealthcare

West

Benefit Interpretation

Policy

Rehabilitation Services

(Physical, Occupational, and Speech Therapy)

Policy Number: BIP148.P

Effective Date: June 1, 2024

 Instructions for Use

Table of Contents Page

Federal/State Mandated Regulations................................... 1

State Market Plan Enhancements ....................................... 4

Covered Benefits ................................................................ 5

Not Covered........................................................................ 6

Definitions ........................................................................... 7

References ......................................................................... 7

Policy History/Revision Information ..................................... 7

Instructions for Use ............................................................. 8

Federal/State Mandated Regulations

Note: The most current federal/state mandated regulations for each state can be found in the links below

Oklahoma

Oklahoma Title 365, Insurance Department Chapter 40. Health Maintenance

Organizations (HMO) Subchapter 5. Life, Accident & Health Division and Consumer

Assistance and Claims Division Rules Part 1 General Provisions

365:40-5-20: Basic Health Care Services

TITLE 365 (ok.gov)

https://regulations.justia.com/states/oklahoma/title-365/chapter-40/subchapter-5/part-5/365-40-5-20/

(4) Outpatient services and inpatient hospital services including short-term rehabilitation services and physical therapy

which the HMO expects can result in the significant improvement of an enrollee's condition within two months

(12) Inpatient and outpatient care for treatment of the birth defect known as cleft lip or cleft palate or both including

medically necessary oral surgery, orthodontics and otologic, audiological, and speed/language treatment.

Oregon

For UnitedHealthcare of Oregon (Clark County, Washington) members only:

Related Benefit Interpretation Policies

• Attention Deficit Hyperactivity Disorder (ADHD)

• Autism Spectrum Disorder

• Biofeedback

• Cognitive Rehabilitation

• Developmental Delay and Learning Disabilities

• Habilitative Services

• Pervasive Developmental Disorder and Autism

Spectrum Disorder

• Skilled Nursing Facility (SNF): Skilled Nursing

Facility (SNF) Care

Related Medical Management Guidelines

• Breast Reconstruction

• Cognitive Rehabilitation

• Habilitation and Rehabilitation Therapy

(Occupational, Physical, and Speech)

• Sensory Integration Therapy and Auditory

Integration Training

UnitedHealthcare Benefits of Texas, Inc.

UnitedHealthcare of Oklahoma, Inc.

UnitedHealthcare of Oregon, Inc.

UnitedHealthcare of Washington, Inc.

Rehabilitation Services (Physical, Occupational, and Speech Therapy)

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RCW Section 48.44.450: Neurodevelopmental Therapies

https://app.leg.wa.gov/RCW/default.aspx?cite=48.44.450

1. Each employer-sponsored group contract for comprehensive health care service which is entered into, or renewed, on

or after twelve months after July 23, 1989, shall include coverage for neurodevelopmental therapies for covered

individual’s age six and under.

2. Benefits provided under this section shall cover the services of those authorized to deliver occupational therapy,

speech therapy, and physical therapy. Benefits shall be payable only where the services have been delivered

pursuant to the referral and periodic review of a holder of a license issued pursuant to chapter 18.71 or 18.57 RCW or

where covered services have been rendered by such licensee. Nothing in this section shall prohibit a health care

service contractor from requiring that covered services be delivered by a provider who participates by contract with

the health care service contractor unless no participating provider is available to deliver covered services. Nothing in

this section shall prohibit a health care service contractor from negotiating rates with qualified providers.

3. Benefits provided under this section shall be for medically necessary services as determined by the health care

service contractor. Benefits shall be payable for services for the maintenance of a covered individual in cases where

significant deterioration in the patient's condition would result without the service. Benefits shall be payable to restore

and improve function.

4. It is the intent of this section that employers purchasing comprehensive group coverage including the benefits

required by this section, together with the health care service contractor, retain authority to design and employ

utilization and cost controls. Therefore, benefits delivered under this section may be subject to contractual provisions

regarding deductible amounts and/or copayments established by the employer purchasing coverage and the health

care service contractor. Benefits provided under this section may be subject to standard waiting periods for

preexisting conditions, and may be subject to the submission of written treatment plans.

5. In recognition of the intent expressed in subsection (4) of this section, benefits provided under this section may be

subject to contractual provisions establishing annual and/or lifetime benefit limits. Such limits may define the total

dollar benefits available or may limit the number of services delivered as agreed by the employer purchasing

coverage and the health care service contractor.

Texas

https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1367.htm#1367.201

Section 1367.201: Definition

In this subchapter, rehabilitative and habilitative therapies include:

1) Occupational therapy evaluations and services;

2) Physical therapy evaluations and services;

3) Speech therapy evaluations and services; and

4) Dietary or nutritional evaluations.

Section 1367.204: Offer of Coverage Required

(a) A health benefit plan issuer must offer coverage that complies with this subchapter.

(b) The individual or group policy or contract holder may reject coverage required to be offered under this section.

Section 1367.205: Coverage of Certain Therapies

a) A health benefit plan that provides coverage for rehabilitative and habilitative therapies under this subchapter may not

prohibit or restrict payment for covered services provided to a child and determined to be necessary to and provided

in accordance with an individualized family service plan issued by the Interagency Council on Early Childhood

Intervention under Chapter 73, Human Resources Code.

b) Rehabilitative and habilitative therapies described by Subsection (a) must be covered in the amount, duration, scope,

and service setting established in the child's individualized family service plan.

c) A child is entitled to benefits under this subchapter if the child, as a result of the child's relationship to an insured or

enrollee in a health benefit plan, would be entitled to coverage under an accident and health insurance policy under

Section 1201.061, 1201.062, 1201.063, or 1201.064

Section 1367.206: Prohibited Actions

Under the coverage required to be offered under this subchapter, a health benefit plan issuer may not:

1) Apply the cost of rehabilitative and habilitative therapies described by Section 1367.205

(a) to an annual or lifetime

maximum plan benefit or similar provision under the plan; or

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2) Use the cost of rehabilitative or habilitative therapies described by Section 1367.205(a) as the sole justification for:

A. Increasing plan premiums; or

B. Terminating the insured's or enrollee's participation in the plan.

Section 1271.156: Benefits for Rehabilitation Services and Therapies

https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1271.htm

a) If benefits are provided for rehabilitation services and therapies under an evidence of coverage, the provision of a

rehabilitation service or therapy that, in the opinion of a physician, is medically necessary may not be denied, limited,

or terminated if the service or therapy meets or exceeds treatment goals for the enrollee.

b) For an enrollee with a physical disability, treatment goals may include maintenance of functioning or prevention of or

slowing of further deterioration.

Washington

RCW Section 18.74.010: Definitions

https://app.leg.wa.gov/rcw/default.aspx?cite=18.74.010

(8) “Physical therapist” means a person who meets all the requirements of this chapter and is licensed in this state to

practice physical therapy.

(9) (a) “Physical therapist assistant” means a person who Meets all the requirements of this chapter and is licensed as a

physical therapist assistant and who performs physical therapy procedures and related tasks that have been

selected and delegated only by the supervising physical therapist. However, a physical therapist may not delegate

sharp debridement to a physical therapist assistant.

(b) “Physical therapy aide” means an unlicensed person who receives ongoing on-the-job training and assists a

physical therapist or physical therapist assistant in providing physical therapy patient care and who does not meet

the definition of a physical therapist, physical therapist assistant, or other assistive personnel. A physical therapy

aide may directly assist in the implementation of therapeutic interventions, but may not alter or modify the plan of

therapeutic interventions and may not perform any procedure or task which only a physical therapist may perform

under this chapter.

subsection, who perform specific designated tasks that are related to physical therapy and within their license,

scope of practice, or formal education, under the supervision of a physical therapist, including but not limited to

licensed massage therapists, athletic trainers, and exercise physiologists. At the direction of the supervising

physical therapist, and if properly credentialed and not prohibited by any other law, other assistive personnel may

be identified by the title specific to their license, training, or education.

(10) “Physical therapy” means the care and services provided by or under the direction and supervision of a physical

therapist licensed by the state. Except as provided in RCW 18.74.190, the use of Roentgen rays and radium for

diagnostic and therapeutic purposes, the use of electricity for surgical purposes, including cauterization, and the use

of spinal manipulation, or manipulative mobilization of the spine and its immediate articulations, are not included

under the term “physical therapy” as used in this chapter.

(11) “Practice of physical therapy” is based on movement science and means:

(a) Examining, evaluating, and testing individuals with mechanical, physiological, and developmental impairments,

functional limitations in movement, and disability or other health and movement-related conditions in order to

determine a diagnosis, prognosis, plan of therapeutic intervention, and to assess and document the ongoing

effects of intervention;

(b) Alleviating impairments and functional limitations in movement by designing, implementing, and modifying

therapeutic interventions that include therapeutic exercise; functional training related to balance, posture, and

movement to facilitate self-care and reintegration into home, community, or work; manual therapy including soft

tissue and joint mobilization and manipulation; therapeutic massage; assistive, adaptive, protective, and devices

related to postural control and mobility except as restricted by (c) of this subsection; airway clearance techniques;

physical agents or modalities; mechanical and electrotherapeutic modalities; and patient-related instruction;

18.200.010. Physical therapists may provide those direct-formed and prefabricated upper limb, knee, and ankle-

foot orthoses, but not fracture orthoses except those for hand, wrist, ankle, and foot fractures, and assistive

technology devices specified in RCW 18.200.010 as exemptions from the defined scope of licensed orthotic and

prosthetic services. It is the intent of the legislature that the unregulated devices specified in RCW 18.200.010 are

in the public domain to the extent that they may be provided in common with individuals or other health providers,

whether unregulated or regulated under Title 18 RCW, without regard to any scope of practice;

(d) Performing wound care services that is limited to sharp debridement, debridement with other agents, dry

dressings, wet dressings, topical agents including enzymes, hydrotherapy, electrical stimulation, ultrasound, and

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other similar treatments. Physical therapists may not delegate sharp debridement. A physical therapist may

perform wound care services only by referral from or after consultation with an authorized health care practitioner;

(e) Reducing the risk of injury, impairment, functional limitation, and disability related to movement, including the

promotion and maintenance of fitness, health, and quality of life in all age populations; and

(f) Engaging in administration, consultation, education, and research.

RCW Section 18.74.012

https://app.leg.wa.gov/rcw/default.aspx?cite=18.74.012

Consultation with health care practitioner no required for certain treatments.

A consultation and periodic review by an authorized health care practitioner is not required for treatment of neuromuscular

or musculoskeletal conditions

RCW 48.44.450: Neurodevelopmental Therapies

https://app.leg.wa.gov/rcw/default.aspx?cite=48.44.450

(1) Each employer-sponsored group contract for comprehensive health care service which is entered into, or renewed, on

or after twelve months after July 23, 1989, shall include coverage for neurodevelopmental therapies for covered

individual’s age six and under.

(2) Benefits provided under this section shall cover the services of those authorized to deliver occupational therapy,

speech therapy, and physical therapy. Benefits shall be payable only where the services have been delivered

pursuant to the referral and periodic review of a holder of a license issued pursuant to chapter 18.71 or 18.57 RCW or

where covered services have been rendered by such licensee. Nothing in this section shall prohibit a health care

service contractor from requiring that covered services be delivered by a provider who participates by contract with

the health care service contractor unless no participating provider is available to deliver covered services. Nothing in

this section shall prohibit a health care service contractor from negotiating rates with qualified providers.

(3) Benefits provided under this section shall be for medically necessary services as determined by the health care

service contractor. Benefits shall be payable for services for the maintenance of a covered individual in cases where

significant deterioration in the patient's condition would result without the service. Benefits shall be payable to restore

and improve function.

(4) It is the intent of this section that employers purchasing comprehensive group coverage including the benefits

required by this section, together with the health care service contractor, retain authority to design and employ

utilization and cost controls. Therefore, benefits delivered under this section may be subject to contractual provisions

regarding deductible amounts and/or copayments established by the employer purchasing coverage and the health

care service contractor. Benefits provided under this section may be subject to standard waiting periods for

preexisting conditions, and may be subject to the submission of written treatment plans.

(5) In recognition of the intent expressed in subsection (4) of this section, benefits provided under this section may be

subject to contractual provisions establishing annual and/or lifetime benefit limits. Such limits may define the total

dollar benefits available or may limit the number of services delivered as agreed by the employer purchasing

coverage and the health care service contractor.

State Market Plan Enhancements

Texas

Members may have additional supplemental benefit coverage for rehabilitative and habilitative services for dependent

children under the age of three with developmental delays as deemed necessary to and in accordance with an

individualized family service plan issued by the Interagency Council on Early Childhood Intervention under Chapter 73,

Human Resources Code. Refer to the state-specific mandated coverage in the Federal/State Mandated Regulations

section.

Washington

Members must receive a referral to access the massage therapy benefit. All services after the initial evaluation and

management visit and up to six consecutive treatment visits in a new episode of care, except Emergency Health Care

Services, must be Preauthorized. For more information or to obtain a list of contracting providers, please contact us at 1-

800-932-3004

Refer to the member’s EOC/SOB for specific benefit limitations.

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Covered Benefits

Important Note: Covered benefits are listed in Federal/State Mandated Regulations, State Market Plan Enhancements,

and Covered Benefits sections. Always refer to the Federal/State Mandated Regulations and State Market Plan

Enhancements sections for additional covered services/benefits not listed in this section.

Notes:

For member specific coverage and limitations for Physical, Occupational and speech therapy and habilitative services,

refer to the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB) or Speech Therapy Amendment.

For habilitative services: Refer to the Benefit Interpretation Policy titled Habilitative Services and the Medical

Management Guideline titled Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech).

The following therapy services are covered in the following settings:

Acute Inpatient Rehabilitation: Inpatient acute rehabilitation provides an intense multidisciplinary service to restore

or enhance function, post injury or illness.

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

o The member requires treatment from a multidisciplinary team consisting of at least two therapies (e.g., Physical

Therapy, Occupational Therapy, speech therapy).

o 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.

o The rehabilitation program is expected to result in significant therapeutic improvement over a clearly defined

period of time.

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

o 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

provided in the member’s medical record must support medical necessity and should include relevant medical

history, including the member’s rehabilitation potential and prior level of function, physical examination, and

results of pertinent diagnostic test or procedures. In addition, the documentation must reflect the ongoing

assessment and necessary adjustments to the plan of care. Current functional status and measurable goals

individualized to the needs and abilities of the member should be part of the plan of care. The member’s progress

toward established goals should be reviewed at least weekly and should include objective measurements (e.g.,

FIM scores) as well as a clinical narrative which demonstrates functional improvement and progress towards

attainable treatment goals as a result of the therapy provided.

Outpatient Physical and Occupational Therapy

o Physician’s office only when done by a licensed therapist and performed in a participating/contracting physician’s

office

o Therapist’s office

o Member’s place of Residence

Physical and Occupational Therapy

Physical, and Occupational Therapy services must meet all of the following criteria:

o Therapy services must be such that only a qualified therapist or a person supervised by a qualified therapist can

safely perform the services.

o Therapy services must be provided with the expectation that the member’s condition will improve or that the

service is necessary to establish a safe and effective maintenance program.

o Physical limitations and goals must be documented and progress recorded.

o Amount, frequency and duration of the therapy services must be reasonable.

o Services must relate directly and specifically to a written treatment plan established by a physician after

consulting with the qualified therapist (Physical and/or Occupational) and/or speech pathologist or audiologist.

Speech Therapy

o Speech therapy evaluation when ordered by a plan physician after a face to face evaluation which documents

some type of deficit and or speech/ language concern

o Speech therapy must be medically necessary. For medical necessity clinical coverage criteria, refer to the

InterQual

LOC: Outpatient Rehabilitation & Chiropractic. Click here to view the InterQual

criteria.

o Ordered by a plan physician after a face to face evaluation including documentation of the member’s abilities to

speak, swallow and/or communicate; if a referral(s) is done copies should accompany the request:

o Speech and language evaluation (face to face) by a speech and language pathologist (speech therapist); or

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o Other appropriate evaluation(s) by a healthcare professional (developmental pediatrician, neurologist;

occupational therapist; psychologist or psychiatrists)

o A plan of care with goals and expected length of time must be submitted by the physician based on the speech

and language therapist’s evaluation or other evaluations; and

o Periodic re-evaluation of the progress toward the goals must be done, no less than every 90 days.

Note: Members with stuttering; lisping; or articulation disorders need to be evaluated for medical necessity. For medical

necessity clinical coverage criteria, refer to the InterQual

LOC: Outpatient Rehabilitation & Chiropractic. Click here to

view the InterQual

criteria.

Physical and Occupational Therapies include, but are not limited to:

Ultrasound, shortwave, and microwave diathermy treatments

Range of motion tests

Gait training

Therapeutic exercises

Aqua/pool therapy, only as part of an authorized treatment plan conducted by a licensed physical therapist with the

therapist in attendance

Fluidized therapy (fluidotherapy) as a part of an authorized physical therapy treatment plan for the treatment of acute

or subacute, traumatic or nontraumatic, musculoskeletal disorders of the extremities

Circumstances under which therapy services are covered include, but are not limited to:

A terminally ill member who begins to exhibit self-care, mobility and/or safety dependence

A member who has an unhealed, unstable fracture of the leg which requires regular exercise until the fracture heals in

order to maintain function of the leg

A member who requires Physical, Occupational, and/or speech therapy for brain injury, when deemed medically

necessary by the member’s network medical group or UnitedHealthcare’s medical director.

Notes:

• There must be a documented need to continue therapy and an estimate of how long the services may be needed. The

physician must review the plan of treatment and the clinical records every 30 days. The member’s limits and goals of

therapy must be included in the documentation.

• Rehabilitation benefit is administered based on treatment episode. Benefit can be renewed within the calendar year if

there is a change in the original condition that warrants additional days of rehabilitation.

• Eligible therapy services received in the home from a home health agency is covered under the home health care

benefit.

• Eligible therapy services received in the home from an independent physical or occupational therapist, not affiliated

with the home health agency, is covered under the rehabilitation benefit.

Autism therapy services, refer to the Benefit Interpretation Policies titled Autism Spectrum Disorder (OR members)

and Pervasive Developmental Disorder and Autism Spectrum Disorder (OK members, TX members, and WA

members).

Not Covered

Therapy when member has either attained therapy treatment plan goals or is unable to attain the treatment plan

goals.

General exercises that promote overall fitness and flexibility and/or solely to improve general physical condition.

Massage therapy unless mandated by state or federal law and/or market plan enhancements (Refer to the

Federal/State Mandated Regulations and State Market Plan Enhancements sections).Recreational therapy.

Maintenance therapy.

Vocational, prevocational and educational assessment and training related solely to specific employment

opportunities, work skills or work settings.

Percutaneous neuromodulation therapy (PNT), also referred to as 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

o Attention deficit hyperactivity disorder

o Dyslexia

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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.

Services that are considered by UnitedHealthcare to be investigational or experimental.

Services that are considered to be custodial.

Work hardening.

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.

Coverage is excluded for 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. An example includes, but

is not limited to, the same day combined use of hot packs, ultrasound and iontophoresis in the treatment of strain.

Hypnotherapy/hypnotic therapy.

Motivational or social activities/therapy.

Definitions

Occupational Therapy: Non-surgical treatment necessary for the identification and alleviation of mental and/or physical

conditions that limit an individual's ability to perform the activities of daily living. Treatment focuses on increasing

independence and minimizing reoccurrence through education and the use of therapeutic exercise and physical activity at

home or at work.

Physical Therapy: Non-surgical treatment necessary for the identification, restoration, and improvement of functions that

have been impaired by illness, disease, surgery, trauma or injury. Treatment includes, but is not limited to, therapeutic

exercise, physical activity, and training in the activities of daily living.

References

Medicare and Retirement, Coverage Summary: Skilled Nursing Facility, Rehabilitation, and Long-Term Acute Care

Hospital (Accessed April 9, 2024).

Medicare Benefit Policy Manual, Chapter 15. Medicare Benefit Policy Manual, Chapter 15, §230 – Practice of Physical

Therapy, Occupational Therapy, and Speech-Language Pathology. (Accessed April 9, 2024)

Policy History/Revision Information

Date

State(s) Affected

Summary of Changes

06/01/2024

All

Covered Benefits

Added reference link to the Medical Management Guideline titled Habilitation

and Rehabilitation Therapy (Occupational, Physical, and Speech) for

habilitative services

Replaced language indicating “therapy services are covered for a member

who requires Physical, Occupational, and/or speech therapy for brain injury,

when deemed medically necessary by UnitedHealthcare’s medical director”

with “therapy services are covered for a member who requires Physical,

Occupational, and/or speech therapy for brain injury, when deemed

medically necessary by the member’s Network Medical Group or

UnitedHealthcare’s medical director”

Added instruction to refer to the Benefit Interpretation Policies titled Autism

Spectrum Disorder and Pervasive Developmental Disorder and Autism

Spectrum Disorder for autism therapy services

Definitions

Removed definition of:

o Acute Rehabilitation Program

o Custodial Care

o Fluidized Therapy (Fluidotherapy)

o Habilitative Services

o Hypnotherapy

o Maintenance Therapy

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Date

State(s) Affected

Summary of Changes

o Multidisciplinary Team Approach

o Outpatient Medical Rehabilitation Therapy

o Primary Residence

o Rehabilitation Services

o Vocational Rehabilitation

o Work Hardening

Supporting Information

Added References section

Archived previous policy version BIP148.O

Washington

Federal/State Mandated Regulation

Revised language pertaining to Revised Code of Washington Section

18.74.010

Instructions for Use

Covered benefits are listed in three (3) sections: Federal/State Mandated Regulations, State Market Plan Enhancements,

and Covered Benefits. All services must be medically necessary. Each benefit plan contains its own specific provisions for

coverage, limitations, and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits

(SOB). If there is a discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will

govern.