Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) – Commercial and Individual Exchange Medical Policyopen_in_new

Covered: outpatient habilitation, rehabilitation, and maintenance occupational, physical, and speech therapy when medically necessary per InterQual Outpatient Rehabilitation criteria; excluded: non‑skilled or custodial care, therapeutic recreation, many school‑based/educational or vocational services, work‑hardening, investigational services, sign‑language interpreters, and other specified limitations. Key requirements: detailed documentation (initial evaluation with diagnosis and baseline objective measures or task‑analysis, measurable/time‑based POC, matching treatment notes and CPTs), regular re‑evaluations (≥ annually or per state), specific rules for group therapy and feeding/swallowing evaluations, and meaningful POC updates to justify continued care.

"Group therapy when there is a "Prescribing provider's order for group therapy" and an individualized treatment plan and required supervision/documentation are provided."