Clinical UM Guideline

This document provides clinical criteria for the use of outpatient physical therapy, occupational therapy, and speech-language pathology services in the hospital outpatient department or hospital outpatient clinic site of care. Provision of these services in other settings is not addressed in this document.

Note: Please see the following related documents for additional information:

• CG-REHAB-12 Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology

Note: The medical necessity of physical therapy, occupational therapy, and speech-language pathology services requested may be separately reviewed against the appropriate criteria. This guideline is for determination of the medical necessity of hospital outpatient site of care for physical or occupational therapy services, or speech-language pathology services.

Medically Necessary:

Outpatient physical therapy, occupational therapy, and speech-language pathology services provided in the hospital outpatient department or hospital outpatient clinic site of care is considered medically necessary when any of the following conditions is present:

1. The prescribed physical therapy, occupational therapy or speech-language pathology regimen requires specialized equipment or services which would only routinely be available in the hospital outpatient department or hospital outpatient clinic setting; or
2. The inherent complexity of, or risk posed by, the prescribed physical therapy, occupational therapy or speech-language pathology regimen is such that it can only be performed safely and effectively by or under the general supervision of skilled medical personnel in the hospital outpatient department or hospital outpatient clinic setting; or
3. The individual's medical status requires enhanced monitoring beyond what would routinely be needed for physical therapy, occupational therapy or speech-language pathology services; or
4. The equipment for the size of the individual (for example, a very young or small child) is not available in a freestanding facility; or
5. There is significant risk of sudden life-threatening changes in the individual’s clinical condition and immediate access to specific services provided in a medical center/hospital setting is considered advisable (for example, access to emergency resuscitation equipment and personnel, inpatient admission or intensive care facilities). Clinical conditions that may warrant such access include, but are not limited to the following:
   1. Acute mental status changes; or
   2. History of falls with significant bleeding; or
   3. History or significant risk of major cardiac event; or
   4. History or significant risk of major thromboembolic event; or
   5. Significant burn care management;
      or
6. There are no other geographically accessible appropriate alternative sites for the individual to receive the prescribed physical therapy, occupational therapy or speech-language pathology regimen.

Not Medically Necessary:

Physical therapy, occupational therapy, and speech-language pathology services in the hospital outpatient department or hospital outpatient clinic site of care are considered not medically necessary, for all other indications, including when criteria above have not been met.

Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

A wide variety of settings may be used to provide physical therapy, occupational therapy, and speech-language pathology services, including hospitals, private practices, outpatient clinics, nursing homes and rehabilitation facilities, and in the home. The location of services is determined by many factors, including the physical and medical condition of the individual receiving treatment, the need for specialized equipment or personnel, and the location of the individual in relation to the needed services. Safety is a major concern, and the location in which services are provided should be adequately resourced and staffed to address any potential medical needs that may arise during a treatment session.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Physical Therapy Association. Access to, admission to, and patient/client rights within physical therapy services. Last updated August 30, 2018. Available at: https://www.apta.org/apta-and-you/leadership-and-governance/policies/access-admission-patient-client-rights. Accessed on February 7, 2024.
2. American Physical Therapy Association. Guide to physical therapist practice. 2^nd Edition revised. American Physical Therapy Association. January 2003. Originally published as: Guide to Physical Therapist Practice. Phys Ther. 2001; 81:9-744.
3. American Physical Therapy Association. Physical therapists’ role in prevention, wellness, fitness, health promotion, and management of disease and disability. September 20, 2019. Available at: https://www.apta.org/apta-and-you/leadership-and-governance/policies/pt-role-advocacy. Accessed on February 7, 2024.
4. American Physical Therapy Association. Physical therapy for older adults. Last updated September 20, 2019. Available at: https://www.apta.org/apta-and-you/leadership-and-governance/policies/pt-for-older-adults. Accessed on February 7, 2024.
5. American Physical Therapy Association. Standards of practice for physical therapy. Last updated August 12, 2020. Available at: https://www.apta.org/apta-and-you/leadership-and-governance/policies/standards-of-practice-pt. Accessed on February 7, 2024.
6. Centers for Medicare & Medicaid Services (CMS). Pub. 100-02, Chapter 15, Section 220. Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance and Section 230 Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology. July 12, 2019. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed on February 7, 2024.
7. Centers for Medicare & Medicaid Services. National Coverage Determination for Institutional and Home Care Patient Education Programs. NCD#170.1. Effective date not posted. Available at: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on February 7, 2024
8. Hillegass E, Puthoff M, Frese EM, et al.; Guideline Development Group. Role of physical therapists in the management of individuals at risk for or diagnosed with venous thromboembolism: evidence-based clinical practice guideline. Phys Ther. 2016; 96(2):143-166.

This Clinical UM Guideline is intended to provide assistance in interpreting Healthy Blue’s standard Medicaid benefit plan. When evaluating insurance coverage for the provision of medical care, federal, state and/or contractual requirements must be referenced, since these may limit or differ from the standard benefit plan. In the event of a conflict, the federal, state and/or contractual requirements for the applicable benefit plan coverage will govern. Healthy Blue reserves the right to modify its Policies and Guidelines as necessary and in accordance with legal and contractual requirements. This Clinical UM Guideline is provided for informational purposes. It does not constitute medical advice. Healthy Blue may also use tools and criteria developed by third parties, to assist us in administering health benefits. Healthy Blue’s Policies and Guidelines are intended to be used in accordance with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.