CurrentAetnaPolicy 0250

Occupational Therapy

This Aetna clinical policy bulletin governs medical necessity, limitations, coding references, and background evidence for occupational therapy (OT) services for Aetna members and applies to providers who deliver or authorize OT services.

Policy Summary

PayerAetna

PolicyOccupational Therapy

Policy CodePolicy 0250

Change TypeNo material change

Effective DateMay 26, 1998

Next Review DateFeb 22, 2024

Key ActionProvide OT only when supported by a written plan of care with documented objectives, frequency/duration, and monthly re-evaluation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60-dayHMO OT limit per condition

97140;97165-68;97535Covered CPT codes (if criteria met)

G0129;G0152;G0160;S9129Covered HCPCS codes (if criteria met)

requiredPlan of care elements

03/29/2023Last review

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Medical Necessity — General OT

Aetna considers occupational therapy medically necessary when ALL of the following are met:

Overall medical necessity requirements: Short-term occupational therapy prescribed by a physician or licensed health care practitioner to learn or re-learn activities of daily living (e.g., bathing, dressing, eating) or compensatory techniques, or to provide task-oriented therapeutic activities designed to significantly improve, develop, or restore physical functions lost or impaired by disease or injury; AND the member's condition can improve significantly based on objective measures within 1 month of therapy start or the proposed services are necessary to establish a safe and effective maintenance program to be performed by the member without ongoing skilled therapy; AND services are proposed for the treatment of a specific illness or injury; AND there is a reasonable expectation that the member's condition will improve significantly in a reasonable and generally predictable period of time; AND services are ordered by a physician or other licensed health care practitioner and performed by a duly licensed and certified (if applicable) occupational therapy provider within the provider's applicable scope of practice; AND the services are of the complexity and nature that require performance by a licensed professional therapist or under their direct supervision as permitted by state law.improvement within 1 month or justified maintenance program

Includes requirement for an ongoing, written plan of care reviewed with and approved by the treating physician and documentation of objective and subjective data to demonstrate medical necessity.

Not covered / Not medically necessary conditions — OT

OT is considered not medically necessary in the following situations:

Not medically necessary situations: Continuing supervised occupational therapy once maximal therapeutic benefit has been achieved or when transition to a home program could be used for further gains; OR occupational therapy for members whose condition is neither regressing nor improving; OR occupational therapy in asymptomatic persons or in persons without an identifiable clinical condition; OR treatments that are maintenance-only or non-skilled (e.g., PROM not part of a restorative program, routine repetitive procedures after initial teaching); OR services intended to improve Instrumental Activities of Daily Living (IADLs) such as meal preparation, laundry, balancing a checkbook, use of public transportation, leisure activities, or driver training/vehicle driving instruction, as these are not considered treatment of disease.N/A

Benefit limits and exclusions may vary by plan (e.g., some HMO/QPOS plans apply a 60-day rehabilitation limit).

Standard Aetna policy excludes coverage for educational training or services. Under plans with this exclusion, occupational therapy provided in educational settings is not covered. Additionally, driver training is excluded because driving is not considered a basic activity of daily living and therefore is not treatment of disease.

A pragmatic cluster randomized controlled trial (Sackley et al., 2016) evaluated a personalized, 3-month course of occupational therapy delivered to care-home residents with stroke-related disabilities. The trial found no significant difference between intervention and usual-care groups on the primary outcome (Barthel Index) at 3 months or on secondary outcomes at later time points, and the economic analysis did not demonstrate meaningful QALY gains. The authors concluded that the individualized 3-month OT course showed no benefit in maintaining functional activity in this older care-home population.

Occupational therapy that is maintenance-only or non-skilled is not considered medically necessary. Services intended primarily to address instrumental activities of daily living (IADLs) (for example, meal preparation, laundry, balancing a checkbook), leisure activities (hobbies, sports, recreation), or driving instruction are excluded from coverage. OT for asymptomatic persons or those without an identifiable clinical condition is also not covered.

Coding

Covered CPT CodesCPTCovered

97140	Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
97165-97168	Occupational therapy evaluation or reevaluation
97535	Self-care/home management training, direct one-on-one contact by provider, each 15 minutes

Covered HCPCS CodesHCPCSCovered

G0129	Occupational therapy requiring the skills of a qualified occupational therapist, furnished as component of a partial hospitalization treatment program, per day
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes
G0160	Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective therapy maintenance program, each 15 minutes
S9129	Occupational therapy, in the home, per diem

Related HCPCS CodesHCPCS

G0158	Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes
G2169	Services performed by an occupational therapist assistant in the home health setting in the delivery of a safe and effective occupational therapy maintenance program, each 15 minutes

ICD-10 codes covered if selection criteria are met (not all-inclusive)ICD-10

A80.0-A80.9	Acute poliomyelitis
B91	Sequelae of poliomyelitis
G12.21	Amyotrophic lateral sclerosis
G14	Postpolio syndrome
G35	Multiple sclerosis
G80.0-G80.9	Cerebral palsy
Q05.0-Q05.9	Spina bifida
Z51.89	Encounter for other specified aftercare

ICD-10 codes not covered for plans that exclude developmental delayICD-10Not Covered

F70-F79	Intellectual disabilities
F80.0-F84.9	Pervasive and specific developmental disorders
F90.8	Attention-deficit hyperactivity disorder, other type
R27.0-R27.9	Other lack of coordination
R47.9	Unspecified speech disturbances

Provider Actions & Documentation

Prior Authorization

Prior Authorization & Medical Necessity

Coverage for the CPT and HCPCS codes listed in this policy is contingent on meeting the medical necessity criteria described in the policy and supported by an ongoing, written plan of care. Prior authorization requirements, where applicable under the member’s benefit plan, will be tied to those medical necessity determinations—providers should consult the full policy and the member’s certificate of coverage for any specific prior authorization procedures.

Prior authorization required when plan/benefit design specifies and only when medical necessity criteria are met.
Check member’s certificate of coverage and prior authorization portals for plan-specific submission requirements.

Documentation Required

Medical Necessity Linked to Written Plan of Care

Occupational therapy must be provided in accordance with an ongoing, written plan of care that is reviewed with and approved by the treating physician and signed by the attending physician and the occupational therapist. Medical necessity is dependent on documentation within that plan of care demonstrating a reasonable expectation of measurable improvement in a reasonable and predictable time frame.

Plan of care must be specific to the diagnosis, presenting symptoms, and findings of the OT evaluation.
The plan of care must be updated as the member’s condition changes and demonstrate progress toward therapy goals.

Denial Risk

Documentation-Based Denial Risks

Failure to maintain the required plan of care or to document the elements listed below may result in denial of services as not medically necessary. Services that are maintenance-only, non‑skilled, or provided without reasonable expectation of measurable improvement are denial triggers.

Lack of an ongoing written plan of care.
Missing signatures from the attending physician and occupational therapist.
Insufficient objective and subjective data demonstrating progress toward goals.

Documentation Required

Plan of Care and Documentation Requirements

The required elements of the plan of care must be present and clearly documented to establish medical necessity and support claims.

A reasonable estimate of when goals will be reached;
Quantitative objectives and specific short-term and long-term goals;
Date of onset or exacerbation of the disorder/diagnosis;
Frequency and duration of treatment;
Specific treatment techniques and/or exercises to be used.
Re-evaluations at least monthly with documentation of progress toward goals.

Note

Provider Responsibility Disclaimer

Clinical Policy Bulletins are tools to assist in administering plan benefits and do not replace clinical judgment. Treating providers remain solely responsible for medical advice and treatment decisions for their patients.

Providers must follow state scope-of-practice and supervision requirements when delivering OT services.
Consult plan benefits and program provisions; CPBs are not guarantees of coverage.

Background and Evidence

Occupational therapy uses purposeful activities to help individuals regain performance skills lost through injury or illness. Medically necessary OT must be restorative in nature or specifically directed to design and teach a maintenance program, be based on a written treatment plan, and require the professional judgment and skills of a licensed occupational therapist. Coverage typically focuses on interventions to improve basic activities of daily living (ADLs) such as bathing, dressing, feeding, grooming, mobility and toileting, rather than IADLs or educational services.

For emphasis, a randomized trial of a personalized, 3-month OT program for care-home residents with stroke-related disability found no benefit on the Barthel Index or secondary functional outcomes and reported minimal incremental QALY gain, supporting the trial authors' conclusion that this intervention did not maintain functional activity in that population.

Definitions

Maintenance care — definition

When it beginsBegins when therapeutic goals of the treatment program are achieved or when no further significant progress is reasonably seen as occurring (plateau often four weeks but may vary by condition).

Examples / contextContinued activities for patients who have achieved generally accepted levels of function and/or muscle strength and are at a plateau or have reached "normal" levels.

Non-skilled services — definition

DefinitionTreatments that do not generally require the skills of a qualified occupational therapist; may be performed by non-skilled personnel or after initial teaching.

ExamplesPassive range of motion (PROM) not part of a restorative program; routine, repetitive procedures that maintain function after initial instruction.

When to escalateIf the intervention requires professional judgment, complex assessment, or skilled techniques documented in a plan of care, it may meet medical necessity as skilled OT.

Ayres Sensory Integration (ASI) — summary

DefinitionAn occupational therapy approach for sensory processing differences used with people with autism spectrum disorder (ASI).

Evidence summarySystematic review (Watling & Hauer 2015) of studies from 2006–2013 found moderate evidence supporting the use of Ayres Sensory Integration (ASI) for people with ASD; sensory-based methods had mixed results.

Research gapsAuthors recommended further higher-level studies with larger samples, use of fidelity measures, and standardized methods for SBIs.

Tele-health occupational therapy — summary

DefinitionOccupational therapy interventions delivered via remote technologies (tele-health).

Evidence summaryA 2022 systematic review (Feldhacker et al.) of 20 studies found strong evidence that tele-health OT is similarly effective as in-person OT for neurological and pain conditions; moderate evidence for education outcomes and low evidence for other pediatric/developmental outcomes.

ScopeIncludes OT delivered independently or as part of interdisciplinary teams across the lifespan, with studies from 2009–2019 reviewed.

OpenPayer

Occupational Therapy

Coverage Criteria

Coding

Provider Actions & Documentation

Background and Evidence

Definitions

Revision History