Clinical UM Guideline

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

Note: For a high-level overview of this document, please see “Summary for Members and Families” below. 

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.

This document describes clinical studies and expert recommendations, and explains when physical therapy, occupational therapy, and speech-language pathology services, also called speech therapy services in the home are clinically appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Rehabilitative and habilitative services provided in the home setting are therapies that help people improve, regain, maintain, or develop important daily living skills. Rehabilitative services help restore skills that were lost because of illness, injury, surgery, or other health conditions. Habilitative services help people learn or improve skills that may not have developed as expected, often because of developmental or congenital conditions. Examples include physical therapy, occupational therapy, and speech-language therapy. These services may help with movement, communication, swallowing, self-care, balance, or other daily tasks.

Rehabilitative and habilitative services are best provided in an appropriately equipped treatment center because these settings offer access to specialized equipment, trained therapy professionals, and a controlled environment designed to support treatment goals. Treatment centers can provide a wider range of therapeutic activities and allow therapists to closely monitor progress, adjust treatment plans, and address safety concerns during therapy sessions. These settings may also provide access to multidisciplinary teams, such as physical, occupational, and speech-language therapists, who can coordinate care and provide more comprehensive services than may be available in the home setting. Home-based therapy should generally be reserved for people whose medical condition makes it very difficult or physically demanding for them to leave their home to receive therapy services.

Studies show that some home-based therapy programs may improve mobility, balance, and daily functioning in certain groups of people such as adults recovering from stroke. However, other studies found little or no added benefit compared with usual care for some home-based rehabilitation programs. Better studies are needed to know which home-based rehabilitation approaches improve health the most for different groups of people. Home-based therapy may also have limits, including difficulty following exercise programs, reduced motivation, or no improvement in some health outcomes.

What the Studies Show

Research has evaluated several types of home-based rehabilitation and habilitation programs. One study of adults recovering from stroke found that a home-based therapy program helped reduce falls and improved balance, mobility, and confidence with daily activities. Another study of older adults with frailty after hospitalization found that extended home-based exercise therapy did not improve quality of life compared with usual care. A separate study found that adding a special activity program to usual home therapy did not improve daily living skills more than usual therapy alone. Other research studied home-based rehabilitation before surgery and telerehabilitation services. A study of older adults preparing for surgery found that home-based exercise and nutrition support did not lower complications or disability after surgery compared with usual care.

A large review from well-regarded experts (the Cochrane Collaboration and the World Health Organization [WHO]) found that telerehabilitation often had little or no difference in daily functioning, balance, quality of life, or mobility compared with in-person care or usual care.

Better studies are needed to know if some rehabilitation delivery methods improve health. Unnecessary or unproven services can lead to treatment that does not help.

When are Rehabilitative and Habilitative Services in the Home Setting Clinically Appropriate?

Physical therapy, occupational therapy, or speech-language therapy services in the home setting may be appropriate in these situations:

• The therapy request meets the medical necessity requirements in the health plan’s physical therapy, occupational therapy, or speech-language therapy criteria; and
• The request also meets the medical necessity requirements for home health care services.

When are Rehabilitative and Habilitative Services in the Home Setting not Clinically Appropriate?

Physical therapy, occupational therapy, or speech-language therapy services in the home setting are not clinically appropriate when the requirements listed above are not met.

Studies show that some home-based rehabilitation programs do not improve quality of life, daily functioning, or recovery more than usual care. Research on telerehabilitation and some home-based exercise programs also found little or no improvement in several health outcomes compared with standard treatment. Better studies are needed to know if these approaches improve health for all groups of people.

(Return to Description)

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:

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

Summary:

Rehabilitative and Habilitative Services in the home Setting refers to health care services provided in an individual’s home that aim to improve or maintain physical, cognitive, and functional abilities.

Rehabilitative services are therapies and treatments provided to help a person regain, maintain, or improve skills and functioning after an illness, injury, or surgery. These services are typically required due to a loss or impairment of function the individual previously had. Examples include physical therapy to recover movement and strength after a stroke or surgery, occupational therapy to restore the ability to perform activities of daily living (ADLs), and speech-language pathology services to regain communication skills or swallowing function. The goals of rehabilitative services are to restore the individual to the highest possible level of function and independence.

Habilitative services are health care services that help a person acquire, maintain, or improve skills and functioning for daily living. Unlike rehabilitative services, habilitative services are provided when the individual has not previously developed these skills, often due to congenital or developmental conditions. Examples include speech therapy for a child with developmental speech delays, occupational therapy for a child with autism to develop sensory integration skills, physical therapy for a child with cerebral palsy to improve mobility. The goal of habilitative services are to promote the development of age-appropriate skills and prevent deterioration of function.

Discussion:

McIsaac (2025) reported the results of a randomized controlled trial that evaluated the effectiveness of a multidisciplinary, home-based intervention to reduce falls in community-dwelling adults after stroke. Participants included adults older than 50 years who were within 5 years of stroke, discharged to the community following rehabilitation, and ambulatory with or without an assistive device. Participants were randomized to receive either a 6-month intervention consisting of habit-forming functional exercise, home fall hazard reduction, and goal-directed community mobility coaching delivered by physiotherapy and occupational therapy teams, or usual care. The primary outcome was the rate of falls over 12 months. Secondary outcomes included community participation, self-efficacy, balance, mobility, physical activity, ADLs, depression, and health-related quality of life. A total of 370 participants were enrolled. At 12 months, the intervention group demonstrated a 33% reduction in fall rates compared with usual care (incidence rate ratio, 0.67; 95% Confidence Interval [CI], 0.48-0.94; p=0.02). However, there was no significant difference between groups in the proportion of participants experiencing at least one fall. Participants receiving the intervention also demonstrated significant improvements in community participation, self-efficacy, mobility, and balance measures. The authors concluded that the home-based intervention may reduce fall rates and improve functional outcomes in ambulatory, community-dwelling adults following stroke.

In 2026, Clegg conducted a multicenter, randomized controlled parallel-group superiority trial evaluating the effectiveness of home-based extended rehabilitation for older adults with frailty following hospitalization for acute illness or injury. Participants were adults aged 65 years or older with mild to severe frailty (Clinical Frailty Scale score 5-7) who were discharged home after hospitalization. Participants were randomized to either the Home-based Older People’s Exercise (HOPE) program, a 24-week progressive home-based exercise rehabilitation intervention, or to usual care. The primary outcome was physical health-related quality of life at 12 months, measured using the physical component summary (PCS) score of the Short Form-36 (SF-36). Secondary outcomes included functional independence, mortality, hospitalizations, and care home admissions at 6 and 12 months. A total of 740 participants were randomized (410 HOPE; 330 usual care). Intention-to-treat analysis demonstrated no significant improvement in physical health-related quality of life among participants receiving the HOPE intervention compared with usual care at 12 months (adjusted mean difference −0.22; 95% CI, −1.47 to 1.03; p=0.73). There was limited evidence suggesting a slightly higher rate of all-cause hospitalizations in the control group. The authors concluded that routine extended home-based rehabilitation following hospital discharge for older adults with frailty after acute illness or injury is not supported by current evidence.

Liu (2026) conducted a single-blind pilot randomized controlled trial evaluating the feasibility and preliminary effectiveness of the Home-based Activity Reactivation Program (HARP) as an adjunct to usual home health therapy in older adults receiving home health care. HARP combined compensatory and restorative approaches designed to calibrate task demands and was delivered through 6 weekly home visits in addition to usual therapy. There were 47 participants (mean age 82.3 ± 7.5 years) who were randomized to receive either HARP plus usual therapy or usual therapy alone. The primary outcome was ADLs motor performance measured by the Motor Skills domain of the Assessment of Motor and Process Skills. Secondary outcomes included measures of physical functioning, mobility, and upper extremity performance. HARP demonstrated strong feasibility, with an 88% completion rate and 95% participant satisfaction among completers. No severe program-related adverse events were reported. There were no statistically significant differences between groups in changes in ADL motor skills at postintervention or at 1-month follow-up. Additionally, no significant between-group differences were observed for secondary functional outcomes over time. The authors concluded that adding HARP to usual home health therapy did not result in superior functional outcomes compared with usual therapy alone. Potential contributing factors included limited usual therapy visits, delays in initiation of HARP, and possible practitioner bias.

A 2026 Cochrane systematic review conducted with the World Health Organization (WHO) Rehabilitation Programme evaluated the effectiveness of rehabilitation delivery arrangements within health systems (Del Furia, 2026). The review included 25 systematic reviews. However, only five reviews were judged to be of moderate or high methodological quality and contributed to the primary synthesis. Outcomes were primarily focused on individual health outcomes, caregiver outcomes, or rehabilitation service utilization, while equity, quality, adverse events, and other health systems outcomes were infrequently reported. Most available evidence evaluated information and communication technologies, particularly telerehabilitation. Advanced practice physiotherapy models may have little to no effect on health outcomes in adults with spinal pain. Among individuals with stroke, telerehabilitation likely has little or no effect on ADLs, quality of life, depression, upper extremity function, or mobility when compared with usual care. Compared with in-person rehabilitation, telerehabilitation may also have little to no effect on ADLs, balance, or upper extremity function. The authors concluded that evidence regarding rehabilitation delivery arrangements remains limited, generally low certainty, and largely derived from high-income countries. Additional high-quality research, particularly in low- and middle-income countries, is needed to evaluate effective rehabilitation delivery strategies and assess organizational, implementation, and equity-related outcomes.

Activities of Daily Living (ADLs): Fundamental self-care tasks essential for maintaining personal independence and functional mobility (American Physical Therapy Association).

Basic Activities of Daily Living (BADLs) are fundamental self-care tasks essential for independent living. They include:

• Bathing - Washing oneself in a bathtub or shower.
• Dressing - Putting on and taking off clothes and managing fasteners.
• Toileting - Getting to and from the toilet, using it appropriately, and cleaning oneself.
• Transferring - Moving in and out of bed, chairs, or wheelchairs.
• Continence - Controlling bladder and bowel functions.
• Feeding - The physical ability to eat (not including meal preparation).

Instrumental Activities of Daily Living (IADLs) are more complex tasks that support an individual’s ability to live independently in a community. They include:

• Managing finances
• Handling transportation (driving or using public transit)
• Shopping for groceries or clothing
• Preparing meals
• Managing medications
• Housekeeping and laundry
• Using communication devices (like phones)

Peer Reviewed Publications:

1. Clegg A, Prescott M, Collinson M, et al. Home-based extended rehabilitation for older people with frailty (HERO): a randomised controlled trial. Age Ageing. 2026; 55(2):afag011.
2. Correction to: Home-based extended rehabilitation for older people with frailty (HERO): a randomised controlled trial. Age Ageing. 2026; 55(3):afag069. Erratum for: Age Ageing. 2026; 55(2):afag011.
3. Clemson L, Scrivener K, Lannin N, et al. FAST Study Group. Home based, tailored intervention to reduce rate of falls after stroke (FAST): randomised trial. BMJ. 2026; 392:e085519.
4. Liu CJ, Rose DK, Qiu P, et al. Functional activities to optimize patient outcomes in home health: a pilot randomized controlled trial. J Am Med Dir Assoc. 2026; 27(5):106147.
5. McIsaac DI, Lee S, Fergusson D, et al. Home-based prehabilitation for older surgical patients with frailty: a randomized clinical trial. JAMA Surg. 2026; 161(2):113-123.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Del Furia MJ, Minozzi S, Battel I, et al. Delivery arrangements for rehabilitation services in health systems: an overview of systematic reviews. Cochrane Database of Syst Rev. 2026;(4):CD016348.

1. American Physical Therapy Association. Clinical Practice Guidelines. Available at: https://www.apta.org/patient-care/evidence-based-practice-resources/cpgs. Accessed on July 31, 2026.

Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

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.

© CPT Only - American Medical Association