UnitedHealthcare modified its SNF, rehab, and LTACH Medicare Advantage coverage policy for outpatient rehabilitation therapy, effective September 26, 2025. Here's what changes for billing teams.
UnitedHealthcare updated policy snf-rehab-ltc-hospitalization to sharpen the medical necessity and "skilled service" definitions governing outpatient PT, OT, speech-language pathology, and chiropractic services under Medicare Advantage. The revision directly affects 39 CPT codes and one HCPCS code — including high-volume codes like 97110, 97140, 97530, 92507, and G0283 — and ties coverage decisions to Local Coverage Determinations and the Optum Health Solutions MSK Utilization Management Program. If your team bills outpatient rehabilitation therapy to UHC Medicare Advantage members, this coverage policy change will affect how you document and what gets paid.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | UnitedHealthcare |
| Policy | Skilled Nursing Facility, Rehabilitation, and Long-Term Acute Care Hospital – Medicare Advantage Medical Policy |
| Policy Code | snf-rehab-ltc-hospitalization |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | High |
| Specialties Affected | Physical Therapy, Occupational Therapy, Speech-Language Pathology, Chiropractic Services |
| Key Action | Audit documentation for skilled service criteria and confirm LCD compliance before billing any code in this set after September 26, 2025 |
UnitedHealthcare Outpatient Rehabilitation Coverage Criteria and Medical Necessity Requirements 2025
The core of this update is a reinforced definition of what counts as a "skilled therapy service" under the UHC SNF rehab LTACH coverage policy. This distinction directly controls reimbursement — and it's where most claim denials will originate.
A service is not skilled just because a licensed therapist performs it. That's the critical line. If the service can be safely delivered by an unskilled person without therapist supervision, UHC will not cover it as a skilled therapy service — even when a credentialed PT, OT, or SLP actually performs it. This applies across CPT codes 97110, 97112, 97116, 97530, 97535, and the full modality range (97012 through 97039).
To meet medical necessity under this policy, each of the following conditions must be satisfied:
| # | Covered Indication |
|---|---|
| 1 | The service must be considered an accepted, specific, and effective treatment for the member's condition under accepted medical practice standards. |
| 2 | The service must relate directly to a written plan of care established before treatment begins — not after. The plan must be written or dictated before the first session. |
| 3 | Services must be provided by qualified personnel under appropriate supervision standards, as defined in Medicare Benefit Policy Manual, Chapter 15, §220.1. |
Skilled therapy services can be covered to improve a patient's condition, maintain their current condition, or prevent or slow further deterioration. That last point matters for long-term patients. Services for general fitness, overall flexibility, diversion, or general motivation do not qualify — even if a licensed therapist delivers them.
For members in states enrolled in the Outpatient Therapy Utilization Management Program, there's an additional layer. Those claims route through the Optum Health Solutions Musculoskeletal (MSK) Utilization Management Policy titled Medicare Outpatient Skilled Therapy (PT/OT/ST). Additional criteria may also apply through the Optum Physical Health Outpatient Rehabilitation Therapy program. Check the provider portal at myoptumhealthphysicalhealth.com to confirm which criteria apply to your state before September 26, 2025.
The policy also requires compliance with any applicable Local Coverage Determinations (LCDs) or Local Coverage Articles (LCAs). Your Medicare Administrative Contractor's LCD for the relevant therapy service governs alongside this policy — not instead of it. If an LCD exists for a code you're billing, both the LCD requirements and the UHC snf-rehab-ltc-hospitalization criteria must be satisfied.
Prior authorization requirements are not explicitly detailed in the policy text, but the Optum MSK program layers in its own utilization management criteria for applicable states. Treat those as effectively functioning as prior auth requirements. If you're unsure whether your state participates, confirm before the effective date.
UnitedHealthcare Outpatient Rehab Therapy Exclusions and Non-Covered Indications
This policy is explicit about what does not qualify for coverage, and the list is broader than it looks on first read.
General wellness and fitness services — general exercises for overall fitness and flexibility, activities for diversion, and services for general motivation — are excluded. This sounds obvious. It isn't in practice, because some notes for maintenance-phase patients slip into this language if documentation isn't tight.
Services without a prior plan of care are not payable. The plan must exist before the first treatment session. Post-hoc documentation will not fix this. If your therapists are writing plans after the first visit, update your workflow now.
Unqualified or improperly supervised personnel. Services provided by staff who don't meet qualification standards, or qualified staff working outside appropriate supervision parameters, are excluded. This affects PT assistants and OT assistants specifically — their supervision requirements are defined in Chapter 15, and UHC will hold to them.
Unskilled services delivered by skilled personnel. If the service could be safely performed without a therapist, billing it under a skilled therapy CPT code is a path to denial and, potentially, a compliance issue. This applies even when 97140, 97530, or 97760 is the code on the claim.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Skilled PT/OT to improve patient condition | Covered | 97110, 97112, 97116, 97530, 97140 | Must meet Ch. 15 §220.1 criteria; plan of care required before treatment |
| Skilled PT/OT to maintain current condition | Covered | 97110, 97530, 97535 | Maintenance-phase documentation must show clinical justification |
| Skilled PT/OT to prevent or slow deterioration | Covered | 97110, 97112, 97530 | Same documentation standards apply |
| Speech-language pathology services (individual) | Covered | 92507 | Skilled service criteria apply; LCD compliance required where applicable |
| Speech-language pathology services (group) | Covered | 92508 | Same as individual; group supervision rules apply |
| Treatment of swallowing dysfunction | Covered | 92526 | Must meet skilled service definition |
| Therapeutic modalities (mechanical, electrical, etc.) | Covered when skilled | 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039 | Covered only when a skilled therapist's judgment is required |
| Electrical stimulation (unattended) | Covered when criteria met | G0283 | HCPCS; not wound care; must document medical necessity |
| Neuromuscular reeducation | Covered | 97112 | Skilled service documentation required |
| Aquatic therapy | Covered | 97113 | Covered when skilled; not general exercise |
| Orthotic management and training | Covered | 97760 | Must document skilled need for assessment and training |
| Prosthetic training | Covered | 97761 | Initial encounter; skilled criteria apply |
| Work hardening/conditioning | Covered | 97545, 97546 | Functional/vocational goals must be documented |
| Assistive technology assessment | Covered | 97755 | Must document clinical need and skilled assessment |
| Community/work reintegration training | Covered | 97537 | Skilled justification needed |
| Wheelchair management | Covered | 97542 | Assessment and fitting; per 15 minutes |
| General fitness/flexibility exercises | Not Covered | — | Explicitly excluded under this policy |
| Diversional or motivational activities | Not Covered | — | Explicitly excluded |
| Services without pre-treatment plan of care | Not Covered | All codes | Plan must be established before treatment begins |
| Services by unqualified/unsupervised staff | Not Covered | All codes | Supervision standards from Ch. 15 apply |
UnitedHealthcare Outpatient Rehab Therapy Billing Guidelines and Action Items 2025
The effective date is September 26, 2025. That's your hard deadline for every item below.
| # | Action Item |
|---|---|
| 1 | Audit your plan-of-care workflow before September 26, 2025. The policy requires the plan of care to be established before treatment begins. If your therapists document the plan after the first session, that's a structural compliance gap. Fix the intake process now — not after a denial. |
| 2 | Review all maintenance-phase patient documentation. If you're billing 97110, 97530, or 97535 for patients in a maintenance phase, documentation must show why skilled care — not unskilled assistance — is clinically required. "Patient requires assistance with exercises" is not enough. State why a licensed therapist's judgment is necessary at each visit. |
| 3 | Confirm which states route through the Optum MSK program. For members in participating states, outpatient therapy billing guidelines route through Optum Health Solutions MSK Utilization Management. Check myoptumhealthphysicalhealth.com for the applicable criteria. Treating these claims the same as non-Optum states will generate denials. |
| 4 | Pull and review every applicable LCD for your codes. The policy requires LCD compliance where applicable. For your Medicare Administrative Contractor's jurisdiction, identify which LCDs govern the CPT codes you bill most frequently — particularly 97110, 97140, 97530, and 92507. Both the LCD criteria and the UHC criteria must be satisfied. |
| 5 | Train therapists and therapy assistants on the "unskilled service" definition. The policy is specific: if a service can be safely performed without a therapist, it's not a skilled service. Therapist assistants billing under direct or general supervision need to understand this distinction in practice, not just in theory. Documentation must reflect the clinical complexity that requires skilled judgment. |
| 6 | Verify supervision documentation for PT assistants and OT assistants. The policy explicitly excludes services where supervision standards aren't met. If you employ PTAs or COTAs, confirm their supervision documentation aligns with Medicare Benefit Policy Manual, Chapter 15, standards — those are what UHC references. |
| 7 | Flag G0283 claims for review. Electrical stimulation (unattended), billed under HCPCS G0283, is in scope for this policy. It's a low-documentation code that attracts scrutiny. Make sure your records establish the medical necessity for unattended electrical stimulation and that it's clearly distinguished from wound care applications. |
If your practice spans multiple states or your patient mix includes a high volume of UHC Medicare Advantage members in maintenance therapy, loop in your compliance officer before September 26, 2025. The Optum MSK layer introduces state-specific variation that a general billing guideline review won't catch.
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Outpatient Rehabilitation Therapy Under snf-rehab-ltc-hospitalization
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 92507 | CPT | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual |
| 92508 | CPT | Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals |
| 92526 | CPT | Treatment of swallowing dysfunction and/or oral function for feeding |
| 97012 | CPT | Application of a modality to 1 or more areas; traction, mechanical |
| 97016 | CPT | Application of a modality to 1 or more areas; vasopneumatic devices |
| 97018 | CPT | Application of a modality to 1 or more areas; paraffin bath |
| 97022 | CPT | Application of a modality to 1 or more areas; whirlpool |
| 97024 | CPT | Application of a modality to 1 or more areas; diathermy (e.g., microwave) |
| 97026 | CPT | Application of a modality to 1 or more areas; infrared |
| 97028 | CPT | Application of a modality to 1 or more areas; ultraviolet |
| 97032 | CPT | Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes |
| 97033 | CPT | Application of a modality to one or more areas; iontophoresis, each 15 minutes |
| 97034 | CPT | Application of a modality to one or more areas; contrast baths, each 15 minutes |
| 97035 | CPT | Application of a modality to one or more areas; ultrasound, each 15 minutes |
| 97036 | CPT | Application of a modality to one or more areas; Hubbard tank, each 15 minutes |
| 97039 | CPT | Unlisted modality (specify type and time if constant attendance) |
| 97110 | CPT | Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength |
| 97112 | CPT | Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception |
| 97113 | CPT | Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercise |
| 97116 | CPT | Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing) |
| 97124 | CPT | Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) |
| 97139 | CPT | Unlisted therapeutic procedure (specify) |
| 97140 | CPT | Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes |
| 97150 | CPT | Therapeutic procedure(s), group (2 or more individuals) |
| 97164 | CPT | Re-evaluation of physical therapy established plan of care |
| 97168 | CPT | Re-evaluation of occupational therapy established plan of care |
| 97530 | CPT | Therapeutic activities, direct (one-on-one) patient contact, each 15 minutes |
| 97533 | CPT | Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes |
| 97535 | CPT | Self-care/home management training (e.g., ADL and compensatory training, safety procedures), direct (one-on-one) patient contact, each 15 minutes |
| 97537 | CPT | Community/work reintegration training (e.g., shopping, transportation, money management), direct (one-on-one) patient contact, each 15 minutes |
| 97542 | CPT | Wheelchair management (e.g., assessment, fitting, training), each 15 minutes |
| 97545 | CPT | Work hardening/conditioning; initial 2 hours |
| 97546 | CPT | Work hardening/conditioning; each additional hour |
| 97755 | CPT | Assistive technology assessment, each 15 minutes |
| 97760 | CPT | Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies), and/or trunk, each 15 minutes |
| 97761 | CPT | Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes |
| 97799 | CPT | Unlisted physical medicine/rehabilitation service or procedure |
Covered HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| G0283 | HCPCS | Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care |
No ICD-10-CM codes are listed in this policy. Diagnosis coding follows standard LCD and Chapter 15 guidance for each covered service.
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