Subject:

Description

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

Clinical Indications

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.