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

Clinical UM Guideline

Subject: Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology
Guideline #: CG-REHAB-12	Publish Date: 10/01/2024
Status: Reviewed	Last Review Date: 08/08/2024

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:

The individual’s therapy request meets medical necessity criteria under the physical, occupational, or speech-language pathology guidelines used by the plan; and
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.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. 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.

When services may be Medically Necessary when criteria are met:

HCPCS
G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes
G0157	Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes
G0158	Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes
G0159	Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes
G0160	Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes
G0161	Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes
G2168	Services performed by a physical therapist assistant in the home health setting in the delivery of a safe and effective physical therapy maintenance program, each 15 minutes
G2169	Services performed by an occupational therapist assistant in the home health setting in the delivery of a safe and effective occupational therapy maintenance program, each 15 minutes
S9128	Speech therapy, in the home, per diem
S9129	Occupational therapy, in the home, per diem
S9131	Physical therapy, in the home, per diem

ICD-10 Diagnosis
	All diagnoses

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

History

Status	Date	Action
Reviewed	08/08/2024	Medical Policy & Technology Assessment Committee (MPTAC) review.
Reviewed	08/10/2023	MPTAC review.
Reviewed	08/11/2022	MPTAC review.
Reviewed	08/12/2021	MPTAC review.
New	08/13/2020	MPTAC review. Initial document development. Moved content from CG-REHAB-04 Rehabilitative and Habilitative Services: Physical Medicine/Physical Therapy; CG-REHAB-05 Rehabilitative and Habilitative Services: Occupational Therapy; and CG-REHAB-06 Rehabilitative and Habilitative Services: Speech-Language Pathology guideline to new clinical utilization management guideline with updated title to address therapy services in the home setting.

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.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.