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On Feb. 21, 2024, Change Healthcare experienced a cyber security incident. Any individuals impacted by this incident will receive a letter in the mail. Learn more about this from Change Healthcare, or reach out to the contact center at 1-866-262-5342.

Revised Clinical Policy for Physical, Occupational and Speech Therapy Services - Effective March 1, 2020

Date: 01/27/20

Superior HealthPlan continually reviews clinical policy to ensure medical necessity review criteria is current and appropriate for our member populations and scope of services provided through our health plan. As a result of the most recent review, Superior is modifying its clinical policy for Physical, Occupational, and Speech Therapy Services for Superior’s Medicaid (STAR, STAR Health, STAR Kids and STAR+PLUS) and CHIP Products. The changes to this clinical policy include revisions to clinical criteria relative to the frequency and duration of therapy services, including high, moderate and low frequency, and including criteria for maintenance level therapy. Policy modification also includes clarification regarding therapy services for Home and Community Based (HCBS) Waiver eligible STAR+PLUS adult members.

Superior’s clinical therapy policy guideline underscores the requirement that the frequency and duration of therapy services must always be commensurate with the member’s medical and skilled therapy needs, level of disability and standards of practice.  Additionally, clinical policy dictates that the determination of frequency and duration of therapy services is not based on the convenience of the member or the responsible adult. Further, Superior expects that frequency and duration requests are individualized for the member, with consideration of the member’s condition and his/her potential to benefit from the formulated treatment plan. Finally, the policy includes specification that therapy requests that exceed the frequency limits in the policy are reviewed by a Superior medical director on a case-by-case basis.

A summary of the clinical criteria effective March 1, 2020, for frequency and duration of therapy services is included in this web posting. Providers may request a complete copy of the revised clinical policy for physical, occupational and speech therapy services by contacting your assigned Account Manager 1-877-391-5921.

Below are several Question/Answers regarding the new clinical policy requirements:

  • For high frequency services, can I only request an authorization period of four weeks? No, requests are for the duration that would be clinically appropriate up to 24 weeks based on the member’s clinical status and response to the treatment plan. For example, a request is written as a request for three times a week for two weeks and then two times a week for 10 weeks or three times a week for four weeks and two times a week for 10 weeks, then one time a week for 10 weeks. There are many variations that may be requested in terms of frequency and duration, however three times a week will only be granted for a limited (four week) duration and under the circumstances described in the clinical criteria.
  • How are acute and chronic conditions defined?  A medical condition is considered chronic when 120 days have passed from the start of therapy, or the condition is no longer expected to resolve or may be slowly progressive over an indefinite period of time. Treatment for chronic conditions is only a benefit of Texas Medicaid for members who are 20 years of age or younger or STAR+PLUS Home and Community Based Services (waiver) members.
  • How do I objectively substantiate my request for a specific frequency and duration? Documentation should address the frequency level descriptions included in the revised therapy policy.
  • Will I be able to request three times a week on re-certification? In most circumstances, three times a week will only be granted for the specified limited duration of four weeks during an initial request when the member’s condition meets the description criteria. In rare cases, with specific medical necessity documentation, a Superior medical director may determine that there is medical necessity to substantiate frequency at three times a week.

High Frequency – Duration of up to four weeks, Frequency three times/week

  • Considered for a limited duration as otherwise requested by the prescribing provider.
  • Requires documentation of medical need to achieve an identified new skill or recover function lost due to surgery, illness, trauma, acute medical condition, or acute exacerbation of a medical condition, with well-defined specific, achievable goals within the intensive period requested.

Exceptions:

  1. The member has a medical condition that is rapidly changing.
  2. The member has a potential for rapid progress (e.g., excellent prognosis for skill acquisition) or rapid decline or loss of functional skill (e.g., serious illness, recent surgery).
  3. The member’s therapy plan and home program require frequent modification by the licensed therapist.

Case by Case:

High frequency for a short-term period (four weeks or less) which does not meet the above criteria may be considered with all of the following documentation:

  1. Letter of medical need from the prescribing provider documenting the member’s rehabilitation potential for achieving the goals identified; and
  2. Therapy summary documenting all of the following:
    • Purpose of the high frequency requested (e.g., close to achieving a milestone).
    • Identification of the functional skill which will be achieved with high frequency therapy.
    • Specific measurable goals related to the high frequency requested and the expected date the goal is achieved.
  3. Higher frequency (four or more times per week) may be considered on a case-by-case basis with clinical documentation supporting why three times a week will not meet the member’s medical needs.

Moderate Frequency – Duration of up to 12 weeks for acute conditions or duration up to 24 weeks for chronic conditions

Therapy provided two times a week may be considered when documentation shows one or more of the following:

  1. The member is making meaningful functional progress toward treatment goals.
  2. The member is in a critical period to gain new skills or restore function or is at risk of regression.
  3. The licensed therapist needs to adjust the member’s therapy plan and home program weekly or more often than weekly based on the member’s progress and medical needs.
  4. The member has complex needs requiring ongoing education of the responsible adult.

Low Frequency – Duration of up to 12 weeks for acute conditions or duration up to 24 weeks for chronic conditions

  • Therapy provided one time per week or every other week may be considered when the documentation shows one or more of the following:
  • The member is making meaningful functional progress toward treatment goals, but the member is nearing discharge where tapering of treatment would be appropriate.
  • Documen­tation shows the member is at risk of deterioration without therapeutic intervention due to the member’s developmental or medical condition.
  • The licensed therapist is required to adjust the member’s therapy plan and home program weekly to every other week based on the member’s progress.
  • Every other week therapy is supported for members whose medical condition is stable, they are making progress, and it is anticipated the member will not regress with every other week therapy.

Note: As the member’s medical need for therapy decreases, it is expected that the therapy frequency will decrease as well.

Maintenance Level/Prevent Deterioration - Duration up to 3 months

For members who are 20 years of age and younger or STAR+PLUS waiver members, this frequency level (e.g., every other week, monthly, every 3 months) is used when the therapy plan changes very slowly, the home program is at a level that may be managed by the member or the responsible adult, or the therapy plan requires infrequent updates by the skilled therapist. A maintenance level or preventive level of therapy services may be considered when a member requires skilled therapy for ongoing periodic assessments and consultations and the member meets one of the following criteria:

  • Progress has slowed or stopped, but documentation supports that ongoing skilled therapy is required to maintain the progress made or prevent deterioration.
  • Documentation shows the member and the responsible adult have a continuing need for education, a periodic adjustment of the home program, or regular modification of equipment to meet the member’s needs.

Note: The reference to “maintenance” in the above statement is applicable to members who are 20 years of age and younger or for STAR+PLUS waiver members.