Coverage Policies

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If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2014 Title: Habilitative Services
Revision Date: 01/01/2021 Document: BI398:00
CPT Code(s): 92507, 92521-92524, 97012-97014, 97018-97036, 97110-97127, 97140, 97161-97168, 97530, 97533, 97535, 97537, 97542, 98940, 98941, 98942, 98943, G0153, S9128, T2012, T2013, T2014, T2015, T2016, T2017, T2018, T2019, T2020, T2021, T2047 and V5362, V5363, V5364, 97129-97130
Public Statement

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).


Medical Statement

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:

ACTIVE

92507

Tx of speech, language, voice, commun, &/or auditory procsng disorder; indiv

92521

Evaluation of speech fluency

92522

Evaluation of speech sound production;

92523

       w/eval of language comprehension & expression

92524

Behavioral & qualitative analysis of voice & resonance

97012

       traction, mechanical

97014

       electrical stimulation

97018

       paraffin bath

97022

       whirlpool

97024

       diathermy

97026

       infrared

97028

       ultraviolet

97032

       electrical stimulation (manual), ea 15 mn

97033

       iontophoresis, ea 15 mn

97034

       contrast baths, ea 15 mn

97035

       ultrasound, ea 15 mn

97036

       Hubbard tank, ea 15 mn

97110

Therapeutic proc, 1+ areas, ea 15 mn; therapy exercises to devel strength &

endurance, range of motion & flexibility

97112

       neuromusc reduce of mvmt, balance, coord, kinesthetic sense, posture/

proprioception for sitting/standing activities

97113

       aquatic therapy w/therapy exercises

97116

       gait training

97124

       massage, incl. effleurage, petrissage and/or tapotement

97127

Therapeutic interventions that focus on cognitive function & compensatory

strategies to manage the performance of an activity, dir pt

contact (new code 1/1/18) (Deleted and replaced by new code 97129 eff 01/01/2020)

97140

Manual therapy techniques, 1+ regions, ea 15 mn

97161

PT Evaluation: low complexity

97162

PT Evaluation: med complexity

97163

PT Evaluation: high complexity

97164

PT Re-evaluation

97165

OT Evaluation: low complexity

97166

OT Evaluation: med complexity

97167

OT Evaluation: med complexity

97168

OT Re-evaluation

97530

Therapeutic activities, direct patient contact, ea 15 mn

97533

Sensory integrative technq to enhance sensory processing & promote adaptive

responses

to environ demands, dir pt contact, ea 15 mn

97535

Self-care/home mgmt training, direct pt contact, ea 15 mn

97537

Community/work reintegr training, direct pt contact, ea 15 mn

97542

Wheelchair mgmt, ea 15 mn

98940

Chiropractic manipulative treatment (CMT); spinal, 1-2 regions

98941

       spinal, 3-4 regions

98942

       spinal, 5 regions

98943

       extra spinal, 1 or more regions

G0153

Speech/Lang services in home/hospice, ea 15 min

S9128

Speech Ther in home, per diem

T2012

Habilitation, educational; waiver, per diem

T2013

       waiver, per hr

T2014

       waiver, per diem

T2015

       waiver, per hr

T2016

       waiver, per diem

T2017

Habilitation, residential; waiver, 15 mn

T2018

Habilitation, supported employment, waiver; per diem

T2019

       per 15 mn

T2020

Day habilitation, waiver; per diem

T2021

       per 15 mn

T2047

Habilitation, prevocational, waiver; per 15 minutes (new code 10/2/2020)

V5362

Speech Screening

V5363

Language Screening

V5364

Dysphagia Screening

97129

Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact; initial 15 min.

97130

each add’l 15 min


Limits

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.


Reference

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)


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.