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Coverage criteria policies

Physical and occupational therapy - habilitative

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for more than 20 visits of habilitative Physical Therapy in a calendar year.

Prior authorization is required for more than 20 visits of habilitative Occupational Therapy in a calendar year.

Occupational Therapy (OT) visits count towards Physical Therapy (PT) limits unless modifier ‘GO’ is used when billing.

When a request for habilitative PT or OT has been determined not to be not medically necessary, the member will not be eligible for further visits in the current or following calendar year unless further clinical evidence that supports medical necessity is submitted and services are determined to qualify for coverage.

Coverage

Habilitative PT and OT or habilitative PT and OT with Sensory Integration Therapy (SIT), as defined below, are generally covered subject to the following indications and your plan documents.

Habilitative therapy services are covered only when provided in a clinic, office or outpatient setting. Coverage of physical or occupational therapy home health services is outside the scope of this policy. See Home Health Service policy for criteria. Occupational therapy must be ordered by either a primary care provider or specialist.

For services that are only covered in the context of a child diagnosed with autism, the member’s autism diagnosis and treatment recommendations must be made by a psychiatrist, psychologist or developmental pediatrician who has training and expertise in autism spectrum disorder and child development.

Many plans have benefit limitations that affect therapy coverage. These may include limiting therapy to a maximum allowable number of visits per calendar or plan year. When a limitation is present and the maximum allowable benefit is exhausted, services will no longer be covered even if the medical necessity criteria described below are met. Please see your plan documents for your specific coverage information.

Indications that are covered

  1. Requests for the initial habilitative PT or OT authorization must include a clinical evaluation with results of current age-appropriate standardized testing. To qualify for coverage, scores must be:
    1. At or below the 10th percentile or 1.5 standard deviations or greater below the norm for the member’s age in ADL or functional motor skills. If testing resulting in standard deviation or percentile ranking cannot be completed due to the member’s condition, a clinical evaluation including age equivalency scores that show at least a 25% delay based upon the age of the member in months will be accepted to meet this criterion. Or
    2. 2.0 standard deviations or greater from the mean in sensory processing skills for coverage of sensory integration therapy.
  2. A treatment plan is required that documents
    1. diagnosis, type of treatment intervention to be performed, and anticipated frequency and duration of services, and
    2. long and short-term treatment goals with projected time frame for achievement, and
    3. clear criteria for discharge from therapy.
  3. Treatment goals and objectives must be specific, measurable, and promote achievement of milestones that are related to the member’s deficits/ areas of delay identified in the standardized testing.
  4. To be eligible for continued habilitative therapy beyond the initial authorization:
    1. Members must continue to demonstrate a significant delay in functional skills as noted in criterion #1. New standardized testing may be requested if results of previous testing are incomplete or deemed to be outdated; and
    2. An updated treatment plan is required that documents
      1. measurable functional improvement toward goals,
      2. the medical necessity for any change in frequency,
      3. a plan for transition to a home program and discharge.
  5. If all of the above criteria are met, habilitative therapy services may be allowed for up to two times per week (up to 104 visits/year) for children through age five and, for those who are receiving therapy for the first time, during the initial year. For continued therapy for children over age five, therapy services may be allowed for up to 1 visit per week with an optional increase to 2 visits per week during the summer (up to 64 visits per year). Children with a diagnosis of autism or pervasive developmental disorder may qualify for increased services if medical necessity is demonstrated in the individual treatment plan.

Indications that are not covered

  1. Therapy is not covered in any of the following circumstances:
    1. Ongoing therapy is primarily custodial or maintenance in nature
    2. Therapy that does not require the skills of a licensed physical therapist (PT) or a licensed occupational therapist (OT)
    3. Member is unable to tolerate or participate in therapy due to a medical, psychological, or other condition; or
    4. Documentation indicates member is unable to participate in therapy goals; or
    5. Measurable progress is no longer being made to justify further therapy; or
    6. Member has met the treatment plan goals.
  2. Requests for additional visits within the current authorization period will not be approved unless the treatment plan provides documentation of a change in the member’s medical condition or functional status. Approved additional visits are subject to the limits outlined in #6 in the “Indications that are covered” section above.
  3. Group therapy, except when used in the context of a child diagnosed with autism
  4. Educational therapy
  5. Community reintegration services
  6. IADL training
  7. Therapy to improve attention, memory, problem solving, organizational skills and time management
  8. Integration of primitive reflexes as standalone treatment
  9. Services that duplicate services that are provided as part of a member’s individual educational plan (IEP) or individual service plan (ISP)
  10. Habilitative therapy provided in the member’s home.
  11. Modalities that are considered experimental/investigational, because reliable evidence does not permit conclusions concerning safety, effectiveness, or effect on health outcomes, including, but not limited to:
    1. Equine or hippotherapy (horse riding therapy)
    2. Metronome therapy

Definitions

Activities of daily living (ADLs) - include everyday activities such as eating, bathing, dressing, toileting, transferring, continence, personal hygiene and mobility necessary to achieve these activities.

Custodial care - supportive services focusing on activities of daily life that do not require the skills of qualified technical or professional personnel, including but not limited to, bathing, dressing, and feeding.

Educational therapy refers to skills that are typically taught in a school or educational setting.

Functional skills - essential activities of daily life (ADLs) common to all members such as dressing, feeding, ambulation, transfers and fine motor skills. Measurable progress emphasizes mastery of functional skills and independence in the context of the member's potential ability as specified within a care plan or treatment goals.

Measurable functional improvement for habilitative therapy will be assessed by comparison of the progress towards goals as documented in current progress reports. The determination of whether measurable progress is being made is at the sole discretion of the medical director and his or her designee and is made on a case by case basis. In cases where progress is questioned, the medical director and his or her designee will consult with the treating therapist, and/or a Physical or Occupational Therapist consultant when making the coverage determination.

Habilitative occupational therapy (OT) or physical therapy (PT) - care rendered by a licensed physical or occupational therapist for conditions which have significantly limited the successful initiation of normal motor development. To be considered habilitative, measurable functional improvement and measurable progress must be made toward achieving functional goals (ADLs), within a predictable period of time toward a member's maximum potential.

Instrumental activities of daily living (IADLs) - activities related to independent living, such as cleaning, using a telephone, shopping, laundry, managing medications, transportation and managing money.

Maintenance care - non-rehabilitative care and supportive services, including skilled or non-skilled nursing care for a member whose condition has not significantly improved or has deteriorated over a measurable period of time (generally a period of time of two months from establishing a functional goal).

Recreational therapy - The prescribed use of recreational activities as treatment interventions to improve functional living competence.

Sensory integration/Processing disorder - thought to be a neural system disorder that causes the sensory system to receive incoming information via the senses in a disorganized manner. Sensory integration therapy (SI) is often used with children diagnosed with autism or other pervasive developmental disorder when the disorder is so severe that the patient is not able to take part in the other goals of the habilitative occupational, physical, or speech therapy program.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

    CPT Code

    Description

    95831

    Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk

    95832

    Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side

    95833

    Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands

    95834

    Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands

    95851

    Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine)

    95852

    Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side

    97012

    Application of a modality to 1 or more areas; traction, mechanical

    97014

    Application of a modality to 1 or more areas; electrical stimulation (unattended)

    97016

    Application of a modality to 1 or more areas; vasopneumatic devices

    97018

    Application of a modality to 1 or more areas; paraffin bath

    97022

    Application of a modality to 1 or more areas; whirlpool

    97024

    Application of a modality to 1 or more areas; diathermy (e.g., microwave)

    97026

    Application of a modality to 1 or more areas; infrared

    97028

    Application of a modality to 1 or more areas; ultraviolet

    97032

    Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes

    97033

    Application of a modality to 1 or more areas; iontophoresis, each 15 minutes

    97034

    Application of a modality to 1 or more areas; contrast baths, each 15 minutes

    97035

    Application of a modality to 1 or more areas; ultrasound, each 15 minutes

    97036

    Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes

    97039

    Unlisted modality (specify type and time if constant attendance)

    97110

    Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

    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

    97113

    Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises

    97116

    Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)

    97124

    Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)

    97139

    Unlisted therapeutic procedure (specify)

    97140

    Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

    97150

    Therapeutic procedure(s), group (2 or more individuals)

    97161

    Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.

    97162

    Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family.

    97163

    Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family.

    97164

    Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family.

    97165

    Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family.

    97166

    Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family.

    97167

    Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family.

    97168

    Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family.

    97530

    Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

    97533

    Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes

    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 by provider, each 15 minutes

    97542

    Wheelchair management (e.g., assessment, fitting, training), each 15 minutes

    97750

    Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes

    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

    97761

    Prosthetic training, upper and/or lower extremity(s), each 15 minutes

    97763

    Orthotic(s)/ prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or

    trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes

    97799

    Unlisted physical medicine/rehabilitation service or procedure

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 800-233-9645.

References

  1. American Academy of Pediatrics, Committee on Children with Disabilities (2001). Developmental surveillance and screening of infants and young children. Pediatrics, 108(1), 192-196.
  2. American Academy of Pediatrics, Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee and Medical Home Initiatives for Children With Special Needs Project Advisory Committee. (2006). Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Reaffirmed 2014. Pediatrics118(1), 405–420. doi:10.1542/peds.2006-123.
  3. Gibson, J., Adams, C., Lockton E., & Green, J. (2013). Social communication disorder outside autism? A diagnostic classification approach to delineating pragmatic language impairment, high functioning autism and specific language impairment. Journal of Child Psychology and Psychiatry, 54(11), 1186-197.
  4. Hall, C. D., Herdman, S. J., Whitney, S. L., Cass, S. P., Clendaniel, R. A., Fife, T. D., … Woodhouse, S. N. (2016). Vestibular rehabilitation for peripheral vestibular hypofunction: an evidence-based clinical practice guideline. Journal of Neurologic Physical Therapy, 40(2), 124-55.
  5. Hayes, Inc. Hayes Medical Technology Directory Report. Hippotherapy for neuromusculoskeletal dysfunction. Lansdale, PA: Hayes, Inc.; August, 2009. Reviewed August, 2013. Archived September, 2014.
  6. Hayes, Inc. Hayes Medical Technology Directory Report. Occupational Therapy for Attention-Deficit/Hyperactivity Disorder (ADHD), Lansdale, PA: Hayes, Inc. March 2017. Reviewed March 2018.
  7. Hamilton, S. S. Developmental coordination disorder: Management and outcome. In: UpToDate, Duryea, T. K., & Bridgemohan, C. (Eds), UpToDate, Waltham, MA. (Accessed on November 1, 2018.)
  8. Hayes, Inc. Hayes Medical Technology Directory Report, Sensory-Based Treatments for Autism Spectrum Disorders, Lansdale, PA: Hayes, Inc. May 2011. Reviewed April 2015, Archived June 2016.
  9. Hayes, Inc. Hayes Medical Technology Directory Report, Sensory Integration Therapy for Non-autistic Children, Lansdale, PA: Hayes, Inc March 2014. Reviewed February, 2018.
  10. Hayes, Inc. Hayes Medical Technology Directory Report, Social Skills Training For Autistic Spectrum Disorders, Lansdale, PA: Hayes, Inc October 2011. Reviewed October 2015, Archived November 2016.
  11. Minnesota Statutes 2016. Public health occupations: physical therapists. Chapter 148,​ §148.76, Subdivision 2.
  12. Simms, M. D., & Jin, X. M. (2015). Autism, language disorder, and social (pragmatic) communication disorder: DSM-V and differential diagnoses. Pediatrics in Review, 36(8), 355-63.
  13. Swineford, L. B., Thurm,A., Baird, G., Wetherby, A. M., & Swedo. S. (2014). Social (pragmatic) communication disorder: a research review of this new DSM-V diagnostic category. Journal of Neurodevelopmental Disorders, 6(1), 41.
  14. Weitlauf, A. S., Sathe, N., McPheeters, M. L., & Warren, Z. E. (2017). Interventions targeting sensory challenges in autism spectrum disorder: A systematic review. Pediatrics, 139(6):e20170347. DOI: https://doi.org/10.1542/peds.2017-0347
  15. Wilkinson, J., Bass, C., Diem, S., Gravley, A., Harvey, L., Maciosek, M. … Vincent, P. Institute for Clinical Systems Improvement. Preventive services for children and adolescents. Updated September 2013.