Coverage Explanation

Rehabilitation in an inpatient, outpatient or home health setting enables the member to achieve a high level of functional independence. Rehabilitation programs common to hospital settings (inpatient or outpatient) include:

• Amputee rehabilitation
• Brain injury rehabilitation
• Cardiac rehabilitation
• Coma stimulation
• Fracture rehabilitation
• General rehabilitation - Physical, speech and occupational therapy (may include the above and additional conditions)
• Pain management
• Pulmonary rehabilitation
• Spinal cord injury rehabilitation
• Stroke rehabilitation

If the member is affiliated with a participating physician group (PPG) and the PPG provides physical rehabilitation and educates the member medically and socially, a formal cardiac rehabilitation program is not necessary.

Rehabilitation programs are directed by a physician experienced or trained in rehabilitation and supported by rehabilitative nursing. The ancillary services of physical therapy (PT) and occupational therapy (OT) are necessary for all of the programs cited.

Psychological and social services should be provided depending on the member's need. In addition to these basic services, brain injury and stroke rehabilitation programs require speech therapy, and the pulmonary rehabilitation program requires respiratory therapy.

In accordance with AB 88 (ch. 534, 1999), health care service plans must provide coverage for the diagnosis and medically necessary treatment, including rehabilitation therapy of severe mental illness, including pervasive developmental disorder or autism.