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HealthPartners

Coverage criteria policies

Physical & occupational therapy – rehabilitative-Minnesota Health Care Programs

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 not required. However, services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial may result if criteria are not met.

  • Occupational Therapy (OT) visits count towards Physical Therapy (PT) limits unless modifier ‘GO’ is used when billing.
Habilitative Therapy is outside the scope of this policy. Please see related content at right for link to policy.

Cognitive rehabilitation is outside the scope of this policy. Please see related content at right for link to policy.

Coverage

PT and OT visits are covered subject to the indications listed below and per your plan documents.

To be covered as a rehabilitative and therapeutic service, physical and occupational therapy must:

  1. Be prescribed by a physician or other licensed practitioner of the healing arts.
  2. Require the skills of at least one of the following: a physical therapist (PT) or occupational therapist (OT) or therapy assistant who is under the supervision of a PT or OT.
  3. Be specified in a plan of care that is reviewed and revised as medically necessary by the recipient’s attending physician or other licensed practitioner of the healing arts, at least once every 90 days.
  4. Be provided to a recipient whose functional status is expected by the physician (or other licensed practitioner of the healing arts) to progress toward or achieve the objectives in the recipient’s plan of care within a 90 day period.
  5. Providers must comply and adhere to all DHS provider manual rules regarding plan of care and documentation.
Specialized maintenance therapy

Specialized maintenance therapy coverage is limited to MHCP recipients aged 20 and under.

Specialized maintenance therapy is a health service specified in the recipient's plan of care and certified by a physician, or other licensed practitioner of the healing arts within the practitioner's scope of practice under state law.

The therapy must be necessary for maintaining a recipient's functional status at a level consistent with his or her physical or mental limitations, and may include treatments in addition to rehabilitation nursing services. MHCP covers specialized maintenance therapy only when provided by any of the following:

  1. Physical therapist
  2. Physical therapy assistant
  3. Occupational therapist
  4. Occupational therapy assistant
  5. Speech-language pathologist

Specialized maintenance therapy must be specified in a Plan of Care that meets the requirements of this section, and provided to recipients whose condition cannot be maintained or treated through only:

  1. Rehabilitation nursing services
  2. Services of other care providers
  3. The recipient, because the recipient's physical, cognitive or psychological deficits result in:
    1. Spasticity or severe contracture that interferes with the activities of daily living or with completing routine nursing care, or that has resulted in decreased functional ability compared to the recipient's previous level of function
    2. A chronic condition that results in physiological deterioration and that requires specialized maintenance therapy services or equipment to maintain strength, range of motion, endurance, movement patterns (functional mobility such as gait, transfers, ambulation, bed or chair mobility), activities of daily living, cardiovascular function, integumentary status, or positioning necessary for completing the recipient's activities of daily living, or decreased abilities relevant to the recipient's current environmental demands

Specialized maintenance therapy must have expected outcomes that are:

  1. Functional
  2. Realistic
  3. Relevant
  4. Transferable to the recipient's current or anticipated environment, such as home, school, community, work
  5. Consistent with community standards

Specialized maintenance therapy must meet at least one of the following characteristics:

  1. Prevent deterioration and sustain function
  2. Provide interventions, in the case of a chronic or progressive disability, that enable the recipient to live at the recipient's highest level of independence
  3. Provide treatment interventions for recipients who are progressing but not at a rate comparable to the expectations of restorative care.

Indications that are not covered

  1. Art and craft activities for the purpose of recreation
  2. Vocational or Educational services, including functional capacity evaluations, except as provided under IEP (individual education plan) related services
  3. Services not medically necessary
  4. Services not designed to improve or maintain functional status of a recipient with a physical impairment or a cognitive or psychological deficit
  5. Specialized maintenance PT/OT and Speech provided to adults aged 21 and older
  6. Services that are not:
    1. Documented in the recipient's health care record
    2. Part of the recipient's plan of care
    3. Services specified in a plan of care that is not reviewed and revised as medically necessary by the recipient’s attending physician or practitioner of the healing arts as defined in this section
    4. Services by more than one provider of the same type for the same diagnosis unless the school district provides the service as specified in the recipient's IEP
    5. A rehabilitation and therapeutic service for which Medicare denies payment because of the provider's failure to comply with Medicare requirements
    6. Services provided by a therapy aide or therapy student
    7. Psychosocial services
    8. Record keeping, documentation and travel time (the transport and waiting time of a recipient to and from therapy sessions)
    9. Services provided by a rehabilitation agency that take place in a sheltered workshop, Day Training and Habilitation center (DT&H), Day Activity Center (DAC), or a residential or group home that is an affiliate of the rehabilitation agency.

Definitions

Functional status: The ability of the person to carry out the tasks associated with daily living.

Restorative therapy: A health service specified in the recipient's plan of care, ordered by a physician or other licensed practitioner of the healing arts within the practitioner's scope of practice under state law, who has certified that the service is designed to restore the recipient's functional status to a level consistent with the recipient's physical or mental limitations.

Specialized maintenance therapy A health service specified in the recipient’s plan of care and certified by a physician or other licensed practitioner of the healing arts within the practitioner's scope of practice under state law that is necessary for maintaining a recipient’s functional status at a level consistent with the recipient’s physical or mental limitations and that may include treatments in addition to rehabilitation nursing services.

Practitioner of the Healing Arts: practitioner of the healing arts includes any person who engages in, or holds out to the public as being engaged in, the practice of medicine or surgery, the practice of osteopathy, or other practitioner of the healing arts whose scope of practice under state law includes diagnosis of disease or health condition and prescribing treatment; for example, physician assistant, nurse practitioner, podiatrist, oral surgeon, dentist, optometrist.

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 1-800-233-9645.

References

  1. Minnesota Health Care Programs (MHCP) Provider Manual-Rehabilitation Services. Revised: 08-03-2016