Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

This policy applies only to metallic (individual and small group) plans that offer coverage for Habilitative services for plan years on or after 1 January 2015.  This policy also applies to FEHBP plans.

1.    Habilitative services require pre-authorization.

2.    Habilitative services are services provided in order for a person to attain and maintain a skill or function that was never learned or acquired and is due to a disabling condition.

3.    Eligible providers are Physical, Occupational and Speech therapists, Chiropractors, and fully licensed Developmental Delay Treatment Clinic Services (DDTCS).

4.    Even though habilitative services are covered only for the above mentioned plans, services designed to assist children with congenital disabilities and developmental delays are available regardless of insurance plan under TEFRA. These programs are sponsored by Arkansas and Federal governments without restriction based on the income or assets of the family.  Therefore, we encourage parents to enroll developmentally impaired or disabled children in the TEFRA program. Information is available on the internet at: http://www.arkansas.gov/dhhs/NewDHS/TEFRA.html.

5.    Rehabilitation services are provided with the expectation of significant restoration of functions lost by illness or injury (which is different from habilitative/developmental services). Rehabilitative services have benefit limitations which are specified in BI020 (Chiropractic Care), BI067 (Speech Therapy) and BI307 (Physical and Occupational Therapy Services).

1.    Habilitative/developmental services (for those plans in which this is a covered benefit) are subject to pre-authorization and a treatment plan with measureable goals for progression, using the attached form.

2.    Developmental services are billed with codes T2013 or T2015.  T2012, T2014 and T2016-T2021 are not covered codes.

3.    For autism treatment, see BI184.

4.    Chiropractic therapy codes are subject to payment limitation noted in BI020.

5.    Speech therapy codes are subject to payment limitations noted in BI067.

6.    Physical/Occupational therapy codes are subject to payment limitations noted in BI307.

Codes Used In This BI:

The following do not meet the medical necessity guidelines, therefore coverage will not be authorized:

•        Therapy when measurable functional improvement is not expected or progress has plateaued.

•        Services that is primarily educational in nature.

·         Services encountered in school settings (e.g. psychosocial speech delay, behavioral problems, attention disorders, conceptual handicap, mental retardation).

·         Services provided by school personnel pursuant to an individual education program are not subject to reimbursement.

·         Services that is not medically necessary.

·         Treatment whose purpose is vocationally or recreationally based.

·         Treatment that is investigational or unproven, including, but not limited to facilitated communication, Auditory Integration Therapy (AIT), Holding Therapy, Higashi (Daily Life Therapy).

·         Respite care, day care, recreational care, residential treatment, social services, custodial care, or education services of any kind.

Addendum: 

1)    Effective 01/01/2017: Updated Claim Statement & Codes Used in This BI section to reflect new/deleted CPT codes. The following codes were deleted 1/1/17: 97001 – 97004. These codes were replaced with the following new codes effective 1/1/17: 97161 – 97168.

2)    Effective 01/01/2018: Updated Codes Used in This BI section to reflect new/deleted CPT codes. The following code was deleted 1/1/18: 97532. This code was replaced with the following new code effective 1/1/18: 97127.

3)    Effective 06/01/2018: Further clarified distinction between habilitative and rehabilitative therapies, which plans cover habilitative services and which policies govern payment limitations on chiropractic, ST and PT/OT service codes. Also combined with policy for services for disabled children to eliminate confusion and duplication.

4)    Effective 01/01/2020: Code update: Added new codes and their descriptions 97129 and 97130 eff 01/01/2020.  Deleted code 97127 eff 01/01/2020

5)    Effective 10/1/2020: New code T2047 added (non-covered)