Clinical Policy: Physical, Occupational, and Speech Therapy Services Form

CENTENE® Corporation

Clinical Policy: Physical, Occupational, and Speech Therapy Services Reference Number: CP.MP.49 Date of Last Revision: 06/25 Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Description To provide guidelines for the authorization of outpatient or home care speech therapy, occupational therapy, and/or physical therapy evaluation and treatment services. Initial evaluation requirements are based on the individual benefit contract.

Note: This policy should only be used if there are no relevant clinical decision support criteria.

Policy/Criteria I. It is the policy of health plans affiliated with Centene Corporation® that initial authorization

for outpatient speech therapy, occupational therapy, and/or physical therapy services is
considered medically necessary when all the following criteria are met:
A.  Signs and symptoms of physical deterioration or impairment in one or more of the
    following areas, or for prevention of disability in one or more of the following areas:
    1.  Sensory/motor ability;
    2.  Functional status as evidenced by inability to perform basic activities of daily living
        (ADLs) and/or mobility;
    3.  Cognitive/psychological ability;
    4.  Cardiopulmonary status;
    5.  Speech/language/swallowing ability/cognitive-communication disorders that result in
        disability;
B.  Treatment is ordered by an examining physician or other qualified healthcare
    professional (e.g., nurse practitioner, physician’s assistant, etc.), and a formal evaluation
    is conducted by a licensed/registered speech, occupational, or physical therapist. The
    evaluation must include all of the following:
    1.  History of illness or disability;
    2.  Relevant review of systems;
    3.  Pertinent physical assessment;
    4.  Current and previous level of functioning;
    5.  Tests or measurements of physical function;
    6.  Potential for improvement in the patient’s physical function;
    7.  Recommendations for treatment and patient and/or caregiver education;
    8.  If request is for speech therapy, the formal evaluation was conducted in the
        member/enrollee’s dominant language;
C.  Treatment requires the judgment, knowledge, and skills of a licensed/registered therapist
    or therapy assistant and cannot be reasonably learned and implemented by non-
    professional or lay caregivers. Repetitive therapy drills which do not require a
    licensed/certified professional’s feedback are not covered services;
D.  Treatment meets accepted standards of discipline-specific clinical practice and is targeted
    and effective in the treatment of the diagnosed impairment or condition;

CLINICAL POLICY Physical Therapy, Occupational Therapy, Speech Therapy

E.  Treatment does not duplicate services provided by other types of therapy or services
    provided in multiple settings;
F.  Treatment conforms to a plan of care (POC) specific to the diagnosed impairment or
    condition. The written POC signed by the therapist must include all of the following:
    1.  Diagnosis with date of onset or exacerbation;
    2.  Short- and long- term functional treatment goals are specific to the diagnosed
        condition or impairment, and measurable relative to the anticipated treatment
        progress. Planned treatment techniques and interventions are detailed, including
        amount, frequency, and duration required to achieve measurable goals;
    3.  Education of the member/enrollee and primary caregiver, if applicable. This should
        include a plan for exercises/interventions to be completed at home between sessions
        with the therapist;
    4.  A brief history of treatment provided to the member/enrollee by the current or most
        recent provider, if applicable;
    5.  A description of the current level of functioning or impairment, and identification of
        any health conditions which could impede the ability to benefit from treatment;
    6.  Most recent standardized evaluation scores, with documentation of age equivalency,
        percent of functional delay, or standard deviation (SD) score, when appropriate, for
        the diagnosis/disability;
    7.  Any meaningful clinical observations, summary of a member’s/enrollee’s response to
        the evaluation process, and a brief prognosis statement;
    8.  Member/enrollee agrees to participation and plan of care;

Note: Standardized scores ≥ 1.5 SD below the mean (except where state requirements differ) may qualify as medically necessary as defined by age equivalent/chronological age; however, such a score may not be used as the sole criterion for determining eligibility for initial or continuing treatment services.

G.  Treatment is expected to do one of the following:
    1.  Produce clinically significant and measurable improvement in the level of functioning
        within a reasonable and medically predictable period of time;
    2.  Prevent significant functional regression as part of a medically necessary program;

Note: If under age 21, and a clinical and functional plateau is achieved, the provider adjusts the POC and provides monthly (or as appropriate) reassessments to update and modify the home care program. If functional level is in jeopardy or declining, the POC can be adjusted accordingly by the therapy provider;

    3.  Address likely loss or regression of present level of function within a reasonable and
        medically predictable period of time;

Note: Where appropriate, nationally recognized clinical decision support criteria will be used as a guideline in the medical necessity decision making process.

H.  If treatment is to be performed in the home, all of the following:
    1.  The treatment can be safely and adequately performed in the home environment;

CLINICAL POLICY Physical Therapy, Occupational Therapy, Speech Therapy

    2.  The diagnosed impairment or condition makes transportation to an outpatient rehab
        facility impractical or medically inappropriate.

II. It is the policy of health plans affiliated with Centene Corporation that continued

authorization for outpatient speech therapy, occupational therapy, and/or physical therapy
services is considered medically necessary when all the following criteria are met:
A.  Treatment progress must be clearly documented in an updated POC/current progress
    summary signed by the therapist and submitted by the requesting provider at the end of
    each authorization period and/or when additional visits are being requested.
    Documentation must include the following:
    1.  Updated standardized evaluation scores with documentation of age equivalency,
        percent of functional delay, or SD score, if applicable;
    2.  Objective measures of functional progress relative to each treatment goal and a
        comparison to the previous progress report;
    3.  Summary of response to therapy with documentation of any issues which have
        limited progress;
    4.  Documentation of member/enrollee participation in treatment, or caregiver’s
        participation if member/enrollee is unable to participate in treatment;
    5.  Documentation of participation in or adherence with a home exercise program (HEP),
        if applicable;
    6.  Brief prognosis statement with clearly established discharge criteria;
    7.  An explanation of any significant changes to the POC and the clinical rationale for
        revising the POC;
    8.  Prescribed treatment modalities with anticipated frequency and duration;
    9.  Physician or other qualified healthcare professional (e.g., nurse practitioner,
        physician’s assistant, etc.) signature must be on the POC or on a prescription noting
        the service type;
    10. If applicable, Individualized Family Service Plan/Individualized Education Program
        (IFSP/IEP) or attestation is submitted and verifies no duplication of services for
        children with developmental delays;
B.  If treatment is to be performed in the home, all of the following:
    1.  The treatment can be safely and adequately performed in the home environment;
    2.  The diagnosed impairment or condition makes transportation to an outpatient rehab
        facility impractical or medically inappropriate.

III.It is the policy of health plans affiliated with Centene Corporation that outpatient speech

therapy, occupational therapy, and/or physical therapy services are no longer medically
necessary when any of the following apply:
A.  Reasons for discontinuing treatment may include, but are not limited to, the following:
    1.  Treatment goals have been achieved as evidenced by one or more of the following:
        a.  No longer demonstrates functional impairment or has achieved goals set forth in
            the POC;
        b.  Has returned to baseline function;
        c.  Will continue therapy with a HEP;
        d.  Has adapted to impairment with assistive equipment or devices;
        e.  Is able to perform ADLs with minimal to no assistance from caregiver;
    2.  A functional plateau in progress has been reached, or additional therapy will no
        longer be beneficial;

Note: A denial of treatment due to “failure to benefit or progress” may be made in those cases when a condition or developmental deficit being treated has failed to be ameliorated or effectively treated despite the application of therapeutic interventions in accordance with the POC, or if maximum medical benefit has been achieved;

    3.  Unable to participate in the POC due to medical, psychological, or social
        complications;
    4.  Non-compliance with a HEP and/or lack of participation in scheduled therapy
        appointments;
B.  Treatment(s) may be re-instituted in accordance with this policy should a documented
    regression occur.

CLINICAL POLICY Physical Therapy, Occupational Therapy, Speech Therapy

IV.It is the policy of health plans affiliated with Centene Corporation that reevaluation

authorization for outpatient speech therapy, occupational therapy, and/or physical therapy
services is considered medically necessary when all the following criteria are met:
A.  A formal reevaluation by a licensed/registered therapist is considered medically
    necessary up to once every six months when there is documentation of one of the
    following (but is not a requirement for assessing the need for continued treatment):
    1.  New clinical findings or a significant change in condition that was not anticipated in
        the POC;
    2.  Failure to respond to therapeutic interventions outlined in the POC.

Background Physical and occupational therapy are defined as therapeutic interventions and services that are designed to improve, develop, correct or ameliorate, rehabilitate or prevent the worsening of physical functions and functions that affect activities of daily living (ADLs) that have been lost, impaired or reduced as a result of an acute or chronic medical condition, congenital anomaly or injury. Various types of interventions and techniques are used to focus on the treatment of dysfunctions involving neuromuscular, musculoskeletal, or integumentary systems to optimize functioning levels and improve quality of life.¹²

Speech therapy is defined as services that are necessary for the diagnosis and treatment of speech and language disorders that result in communication disabilities and for the diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presence of a communication disability. The member/enrollee should have at least part of their evaluation conducted in their dominant language. Those who speak a language other than English should be tested in their primary language.⁸ Speech therapy is designed to correct or ameliorate, restore or rehabilitate speech/language communication and swallowing disorders that have been lost or damaged as a result of chronic medical conditions, congenital anomalies or injuries.³

“Medically Necessary Services” refers to services or treatments ordered by an examining physician or other qualified healthcare professional (e.g., nurse practitioner, physician’s assistant, etc.) which, pursuant to the Early and Periodic Screening, Diagnosis and Treatment

CLINICAL POLICY Physical Therapy, Occupational Therapy, Speech Therapy

(EPSDT) Program, diagnose or correct or significantly ameliorate defects, physical and mental illnesses, and health conditions. “Correct” or “ameliorate” means to optimize a health condition, to compensate for a health problem, or to prevent serious medical deterioration, or to prevent the development of additional health problems.⁴

CLINICAL POLICY Physical Therapy, Occupational Therapy, Speech Therapy

Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy,

CLINICAL POLICY Physical Therapy, Occupational Therapy, Speech Therapy

contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.