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Exclusions and Limitations

Provider Type

  • Physicians
  • Ancillary
  • Participating Physician Groups (PPG)

Rehabilitation therapy (physical, speech and occupational) is not covered when such problems are the result of the following conditions. Note: This does not apply to members with Mental Health and Substance Use Disorders. In such cases, therapy that develops or restores functioning to the maximum extent practicable is considered medically necessary when rehabilitation or habilitation therapy criteria is met.

  • Psychosocial speech delay (includes delayed language development)
  • Syndromes associated with diagnosed disorders attributed to perceptual and conceptual dysfunctions
  • Attention deficit disorders (ADD) and associated behavior problems
  • Developmental articulation and language disorders (such as stuttering and lisping)
Last Updated: 12/19/2024