Rehabilitative Services Form

Page 1 of 9 Rehabilitative Services Policy Last Reviewed / Revised: 5/30/2025 ALOHACARE Policy Number: MP-33 Policy Name: Rehabilitative Services Policy Line of Business: QUEST Integration (Medicaid), Medicare Place(s) of Service: Outpatient Original Effective Date: 10/20/25 Review/Revision Dates: N/A Prior Authorization: Required, refer to Section V

Attachment(s): No

I. PURPOSE

This policy outlines the clinical criteria required for coverage of physical, occupational therapy, and speech therapies. It is designed to ensure that such services are used appropriately in medically necessary situations. II. DESCRIPTION

Physical therapy (PT) is the treatment of disease or injury using therapeutic exercise and other interventions that focus on range of motion, improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, and on alleviating pain. Physical therapy also integrates all the above, so a patient may regain functional activities of daily living. Treatment may include active and passive modalities using a variety of means and techniques based upon biomechanical and neurophysiological principles. Occupational therapy (OT) evaluates and treats neuromusculoskeletal and psychological symptoms or disorders through the use of specific tasks or goal-directed activities designed to improve the functional performance of an individual. Occupational therapy involves cognitive, perceptual, safety, and judgment evaluations and training related to activities of daily living. Occupational therapy also includes the design, fabrication, and use of orthoses, guidance in the selection and use of adaptive equipment, and sensory-integrative and perceptual-motor activities. Speech therapy (ST) is a Medicaid covered treatment service, provided by a qualified, licensed speech therapist/pathologist to restore, maintain or improve the patient’s function. Speech therapy is covered if it is directed toward evaluation and treatment of disorders that impair speech, voice, language, or swallowing.

Page 2 of 9 Rehabilitative Services Policy Last Reviewed / Revised: 5/30/2025 Rehabilitative services for members must be determined to be medically necessary based on clinical evaluation and evidence-based criteria. Coverage decisions are based on a qualified healthcare provider’s assessment of the member’s medical condition and functional limitations. Services recommended solely for educational purposes or to enhance academic performance— such as those suggested by an Individualized Education Program (IEP) or school-based team— are not considered medically necessary and are not covered under this policy. III. POLICY CRITERIA:

Physical therapy and occupational therapy are covered if all the following criteria have been met:
A. The therapy must be ordered by a physician or other licensed health care practitioner who has established the member’s diagnosis and is qualified to prescribe physical therapy or occupational therapy within the scope of work. B. The therapy must be provided by a physical therapist or physical therapist assistant who must practice within the scope of licensure under the supervision of the physical therapist. C. The therapies are ordered to improve, develop, or restore neurological and/or musculoskeletal functions lost or impaired due to disease, trauma, surgical procedures, congenital anomalies, or prior therapeutic intervention. D. The therapy is to achieve a specific diagnosis-related goal for a member who has a reasonable expectation of achieving significant improvement in a reasonable and predictable period of time. Significant is defined as a measurable and meaningful increase (as documented in the patient’s record) in the patient’s level of physical and functional abilities that can be attained with short-term therapy, usually within a three- month period. Measures of progress include: a. Physical therapy i. Active range of motion ii. Strength iii. Motor exam iv. Functional abilities b. Occupational therapy i. Useful and purposeful activities (neuromusculoskeletal) ii. Guidance in the selection and use or orthoses iii. Functional abilities (skill and deficits) E. The therapy must include a home exercise/education program to be initiated at the first physical therapy visit. The physical therapist or the physical therapist assistant must document the member’s participation in and compliance with the home exercise/education program. F. The frequency of visits shall be appropriate according to the member’s physical condition and stage of healing.

Page 3 of 9 Rehabilitative Services Policy Last Reviewed / Revised: 5/30/2025 IV. LIMITATIONS

A. PT or OT is not covered when any other therapy is provided concurrently with the same interventions and treatment for the same purpose.
B. PT and OT are not covered for the following purposes:

1. Leisure activities include hobbies, sports, or recreation of all types even if suggested as part of a PT treatment plan. This includes continued treatment for sports related injuries to improve above and beyond normal ability to perform activities of daily living; it is not intended to return the individual to their previous (or improved) level of sports competition or capability
2. Ongoing treatment solely to improve endurance and distance
3. General exercise programs to promote overall fitness
4. Programs to provide diversion or general motivation
5. Long term therapy
6. Developmental delay defined as any significant lag in a child's physical, cognitive, behavioral, emotional, or social development, in comparison with norms
7. Conditions considered as routine educational, training, conditioning, or fitness
8. Remote or tele-health physical therapy C. PT and OT are considered not medically necessary if:
9. Member’s condition does not show improvement
10. The function could reasonably be expected to improve as the member gradually resumes normal activities
    D. The following modalities are not reimbursed separately with the therapy since they are considered as components of comprehensive PT or OT treatment plan:
11. Functional activities and activities of daily living
12. Infrared and ultraviolet
13. Massage therapy and myofascial release
14. Microwave and infrared
15. Orthotics training and prosthetic training
16. Whirlpool and Hubbard tank
    E. The following physical therapy interventions are considered experimental, investigational, or unproven to be effective by scientific studies. a. Electrical stimulation (E-stim/NMES) for swallowing/feeding disorders is not covered as it is not known to improve health outcomes.
    b. Adhesion removal for bowel obstruction c. Applied Functional Science d. Blood flow restriction therapy e. Dynamic Movement intervention f. Kinesio Taping/McConnell Taping g. “Hands free” ultrasound and low-frequency sound (infrasound) h. Hivamat therapy (deep oscillation therapy) i. Interactive Metronome program

Page 4 of 9 Rehabilitative Services Policy Last Reviewed / Revised: 5/30/2025 j. Low-dye strapping for the treatment of stress fracture of the ankle k. Cuevas Medek exercises l. RomTech PortableConnect
m. Strapping of chest and/or hip for treatment of pain and improvement of posture n. Ultrasound therapy for treatment of Dupuytren’s contracture o. Virtual reality facilitated gait training

V. ADMINISTRATIVE GUIDELINES

A. Prior Authorization (PA) is not required for the first 2 evaluations of PT and/or OT within a six-month period. B. PA is not required for one PT or OT treatment on the same day with the initial evaluation and re- evaluation visits. C. PA is required for the following:

1. Evaluation and treatment for speech therapy.
2. Changes in treatment plan. D. Documentation submitted along with PA must include an individualized, written treatment plan that include the following information:
3. Diagnosis, symptoms and findings of the evaluation which clearly documents the medical necessity of the treatment
4. The date of onset or exacerbation of the disorder or diagnosis
5. Long-term and short term-goals that are specific, measurable, attainable, relevant, and time bound. Goals should include a transition from one-to-one supervision to a member, family member or caregiver upon discharge to a home maintenance program
6. Therapy evaluation
7. Measurable objectives intended to facilitate significant functional improvement
8. A reasonable estimate of when the goals will be reached
9. Frequency and duration of treatment specifically citing the intended procedure codes to be used during each session (e.g., procedure codes associated with 15- minute modalities)

10. The specific procedures and/or modalities to be used in treatment, including those for use in a home maintenance program.

    The following medical codes are relevant codes for diagnosis and procedures for physical therapy and occupational therapy and should be used for informational purposes only. All the medical codes listed in this policy do not constitute or imply benefit coverage or guarantee provider reimbursement.

Page 5 of 9 Rehabilitative Services Policy Last Reviewed / Revised: 5/30/2025 Table 1: CPT / HCPCS Description PA Policy 64550
Application of surface (transcutaneous) neurostimulator (e.g., TENS unit)
Yes
90901
Biofeedback training by any modality
Yes
90911
Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry
Yes
92507
Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
Yes
92508
Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals
Not covered
92520
Laryngeal function studies (i.e., aerodynamic testing and acoustic testing)
Yes
92521
Evaluation of speech fluency (e.g. stuttering, cluttering)
Yes
92522
Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria);
Yes
92523
Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language)
Yes
92524
Behavioral and qualitative analysis of voice and resonance
Yes
92526
Treatment of swallowing dysfunction and/or oral function for feeding
Yes
92597
Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech
Yes
92605
Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face- to-face with the patient; first hour
Yes
92606
Therapeutic service(s) for the use of non-speech-generating device, including programming and modification
Yes
92607
Evaluation for prescription for speech-generating augmentative and alternative communication device, face- to-face with the patient; first hour
Yes
92608
Evaluation for prescription for speech-generating augmentative and alternative communication device, face- to-face with the patient; each additional 30 minutes (List separately in addition to code for primary procedure)
Yes
92609
Therapeutic services for the use of speech-generating device, including programming and modification
Yes
92610
Evaluation of oral and pharyngeal swallowing function
Yes
92611
Motion fluoroscopic evaluation of swallowing function by cine or video recording
Yes
92612
Flexible endoscopic evaluation of swallowing by cine or video recording;
Yes

Page 6 of 9 Rehabilitative Services Policy Last Reviewed / Revised: 5/30/2025 CPT / HCPCS Description PA Policy 92614
Flexible endoscopic evaluation, laryngeal sensory testing by cine or video recording;
Yes
92616
Flexible endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording;
Yes
92618
Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face- to-face with the patient; each additional 30 minutes (List separately in addition to code for primary procedure)
Yes
95831
Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk
Yes
95832
Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side
Yes
95833
Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands
Yes
95834
Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands
Yes
95851
Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine)
Yes
95852
Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side
Yes
95992
Canalith repositioning procedure(s) (e.g., Epley maneuver, Semont maneuver), per day
Yes
96105
Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour
Yes
96111
Developmental testing, (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments) with interpretation and report
Yes
96125
Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of a qualified health care professional's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report
Yes
97010
Application of a modality to 1 or more areas; hot or cold packs
Yes
97012
Application of a modality to 1 or more areas; traction, mechanical
Yes
97014
Application of a modality to 1 or more areas; electrical stimulation (unattended)
Yes

Page 7 of 9 Rehabilitative Services Policy Last Reviewed / Revised: 5/30/2025 CPT / HCPCS Description PA Policy 97016
Application of a modality to 1 or more areas; vasopneumatic devices
Yes
97018
Application of a modality to 1 or more areas; paraffin bath
Yes
97022
Application of a modality to 1 or more areas; whirlpool
Yes
97024
Application of a modality to 1 or more areas; diathermy (eg, microwave)
Yes
97026
Application of a modality to 1 or more areas; infrared
Yes
97028
Application of a modality to 1 or more areas; ultraviolet
Yes
97032
Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
Yes
97033
Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
Yes
97034
Application of a modality to 1 or more areas; contrast baths, each 15 minutes
Yes
97035
Application of a modality to 1 or more areas; ultrasound, each 15 minutes
Yes
97036
Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes
Yes
97039
Unlisted modality (specify type and time if constant attendance)
Yes
97110
Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
Yes
97112
Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
Yes
97113
Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises
Yes
97116
Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)
Yes
97124
Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
Yes 97139
Unlisted therapeutic procedure (specify)
Yes
97140
Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes
Yes
97150
Therapeutic procedure(s), group (2 or more individuals)
Yes 97161-97164
Physical therapy evaluation and re-evaluation
No PA
for 2 evaluations within a 6- month period 97165-97168
Occupational therapy evaluation and re-evaluation
No PA

Page 8 of 9 Rehabilitative Services Policy Last Reviewed / Revised: 5/30/2025 CPT / HCPCS Description PA Policy for 2 evaluations within a 6- month period
97530
Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes
Yes
97532
Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes
Yes
97533
Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes
Yes 97535
Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes
Yes
97537
Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes
Not covered
97542
Wheelchair management (e.g., assessment, fitting, training), each 15 minutes
Yes
97750
Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes
Yes
97755
Assistive technology assessment (e.g., to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes
Yes 97760
Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes
Yes
97761
Prosthetic training, upper and/or lower extremity(s), each 15 minutes
Yes
97762
Checkout for orthotic/prosthetic use, established patient, each 15 minutes
Yes
97799 Unlisted physical medicine/rehabilitation service or procedure Yes

Page 9 of 9 Rehabilitative Services Policy Last Reviewed / Revised: 5/30/2025 CPT / HCPCS Description PA Policy G0283
Electrical stimulation, (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
Yes
G0451
Development testing, with interpretation and report, per standardized instrument form
Yes

IMPORTANT REMINDER

This policy has been developed through consideration of the medical necessity criteria under Hawaii’s Patients’ Bill of Rights and Responsibilities Act (Hawaii Revised Statutes §432E- 1.4) or for QUEST members under Hawaii Administrative Rules (HAR 1700.1-42), generally accepted standards of medical practice and review of medical literature and government approval status.

REFERENCES AND RESOURCE DOCUMENTS

A. Centers for Medicare and Medicaid Services. Chapter 5- Outpatient Rehabilitation and CORF/OPT Services REV. 11129, 11-22-21. B. Centers for Medicare and Medicaid Services. Chapter 15 – Covered Medical and Other Health Services. REV. 13051, 01-16-25. C. Medquest Manual https://medquest.hawaii.gov/content/dam/formsanddocuments/resources/Provider- Resources/provider-manuals/PMChp17.pdf