Physical Therapy
Customize your policy alerts
Sign up for Aetna Policy 0325 alerts
Get alerted when Policy 0325 changes without checking for updates manually.
Monitor payer policy activity
This Aetna clinical policy bulletin defines medical necessity, coverage limitations, and coding for physical therapy (PT) services, and applies to providers and members subject to Aetna benefit plans.
No material clinical or coverage changes in this revision.
Coverage Criteria and Clinical Policy
Initial medical necessity
Covered when ALL of the following are met:
From policy medical necessity section
Limitations and maintenance
Also required/considered:
Plan-of-care documentation requirement (see Appendix)
Exclusions and NMN statements
Maintenance care definition and implication
Experimental / Investigational
The following interventions are considered experimental/investigational (not an all-inclusive list):
Listed experimental/investigational interventions
Gait Training
Covered when ALL of the following are met
Not medically necessary when walking ability is not expected to improve; supervision of repetitive walk-strengthening for feeble/unstable patients is not considered medically necessary.
Neuromuscular Reeducation
Covered when ALL of the following are met
Ultrasound
Covered when ALL of the following are met
Ultrasound is considered experimental/investigational for asthma, bronchitis, other pulmonary conditions, and Dupuytren's contracture.
Modalities and Duplicative Services
Coverage stance and limitations
Orthotic/Prosthetic Training and Checkout
Covered when ALL of the following are met
Periodic revisits beyond 3 months may be reviewed for medical necessity.
Augmented Soft Tissue Mobilization (ASTM) and ThermoStim Probe
Coverage stance
Typical treatment frequency 1–2 times/week; sessions often ~30 minutes including exercise.
ThermoStim allows electrical stimulation which is covered under electrical stimulation policy when applicable.
Interactive Metronome (IM)
Coverage stance
Small case series and limited studies report selective improvements but are not conclusive.
Kinesio / McConnell / Taping
Coverage stance
Further research recommended; taping is generally considered adjunctive rather than first-line monotherapy.
Patellofemoral pain — taping role
Summary statements regarding taping and patellofemoral pain consensus
Consensus statement: consider adjunctive use and individualization of taping approach.
McConnell taping — evidence insufficient
Review conclusion regarding McConnell taping
Review included heterogeneous studies (n=220) with moderate-to-low risk of bias.
Hands-free ultrasound — investigational/inferior heating
Hands-free ultrasound effectiveness compared to manual ultrasound
May be considered investigational/unproven for therapeutic ultrasound delivery.
Kinesio taping — limited short-term evidence
Kinesio taping evidence
Further well-designed trials are needed.
Modality-specific evidence summaries
Findings summarized from cited studies — coverage stance depends on strength of evidence and investigational status.
May be considered investigational/unproven for therapeutic ultrasound delivery
Considered experimental/investigational pending higher-quality RCTs
Not supported by current literature in these sections
May be considered where clinical judgment supports use; evidence limited
May be supported for short-term symptom relief; further evidence needed for long-term benefit
Evidence-linked coverage considerations
Coverage-relevant evidence summaries
Clare et al and Machado et al reported short-term benefits; long-term effects uncertain.
Petersen (2015) found McKenzie superior to manipulation across subgroups but further study needed.
Evidence for extremity applications is sparse.
~29% of PT group crossed over to surgery during follow-up.
APM versus physical therapy (non-obstructive meniscal tears)
Findings relevant to coverage decisions — evidence-based comparisons
Details: APM improved IKDC by +26.2, PT by +20.4; between-group difference 3.6 points (97.5% CI: -∞ to 6.5); 29% of PT group underwent APM during follow-up.
Hip-targeted PT for LBP
Hip-targeted PT for low back pain
Evidence judged high risk of bias.
Post-hip fracture home PT
Post-hip fracture home PT
Both groups received home visits; adverse events reported.
Myofascial PT for CPPS
Myofascial physical therapy for chronic pelvic pain syndrome (CPPS)
Evidence insufficient for broad coverage conclusions; may be considered where clinical judgment supports use.
Modalities lacking evidence
Modalities lacking evidence
Listed as lacking evidence in document.
Virtual reality gait training
Virtual reality (VR) facilitated gait training
Adverse events (eg, dizziness) reported in some trials; therapist role and intervention details should be documented.
Physiotherapy and BDNF
PT effects on biomarkers
Covered with documentation and clinician judgement
Covered with documentation and clinician judgement
Plan-of-care documentation required; see documentation module for specifics.
Evidence limited by heterogeneity, small samples, and risk of bias.
Derived from meta-analysis of 19 RCTs.
Document therapist role and rationale.
Sports rehabilitation and avocational/competitive activities (for example, organized team sports, professional or amateur dance, competitive weightlifting, and similar pursuits) are not considered the treatment of disease and therefore are excluded from coverage. These services are defined as therapy directed at improving above-and-beyond performance for sport or hobby participation rather than restoring activities of daily living or correcting loss of function. Check the member's benefit plan for any applicable limits (for some Aetna plans, short-term PT benefits accumulate toward a 60‑day treatment period).
Therapeutic ultrasound is described as a deep-heat modality that may be medically necessary for select musculoskeletal indications (e.g., arthritis, periarticular inflammation, neuromas, and softening adhesive scars) when applied according to usual practice — typically 3–4 treatments per week for 1 month. Ultrasound is considered experimental/investigational and not supported for non‑musculoskeletal indications such as asthma, bronchitis or other pulmonary conditions and for Dupuytren's contracture.
A hands‑free ultrasound delivery mode (a stationary transducer/device that allows unattended pulsing of the ultrasound beam) has been evaluated and the Centers for Medicare & Medicaid Services (CMS) has deemed delivery of ultrasound via a hands‑free unit investigational.
Evidence from a small controlled study comparing a hands‑free unit with manual (clinician‑held) ultrasound demonstrated significantly lower tissue heating with the hands‑free device, particularly at deeper tissue depths (notably at 2‑cm), and therapeutic heating at depth was not achieved. Because the hands‑free method did not produce equivalent intramuscular temperature increases, its effectiveness for standard therapeutic ultrasound indications is unproven and services billed as equivalent to manual ultrasound may be at risk for non‑coverage or prior‑authorization review.
An UpToDate review of rehabilitation in palliative care does not describe or recommend the McKenzie classification-based methods (Mechanical Diagnosis and Therapy) in palliative care contexts. This absence indicates that McKenzie techniques are not specifically endorsed by that resource for palliative care patients.
UpToDate topic reviews on stress fractures and on hip pain/approach to hip conditions do not mention strapping (e.g., low‑dye strapping or chest/hip strapping) as recommended management options, implying strapping is not supported as a standard therapeutic approach for ankle stress fractures or for unspecified hip pain in those reviews.
Multiple systematic reviews of virtual reality‑based therapies (VRBT) report short‑term improvements in gait and balance outcomes in neurologic populations, but the included studies are heterogeneous, often small, and assessed primarily short‑term endpoints. As a result, evidence for sustained medium‑ and long‑term functional benefits is insufficient to support routine long‑term coverage without clearer demonstration of durable outcomes and prescribed dosing.
This Clinical Policy Bulletin provides a general description of physical therapy coverage, medical necessity criteria, limitations and evidence summaries to assist in administering plan benefits. It does not constitute a contract and specific coverage depends on the member's plan provisions; providers should consult the written benefit plan and document services in accordance with the required ongoing, written plan of care.
Physical therapy is considered not medically necessary (and may be denied) when provided to asymptomatic persons or to individuals without an identifiable clinical condition; when the condition is neither regressing nor improving; when continuing supervised PT is unnecessary because therapeutic goals have been met or a home exercise program would suffice; and for gait training when the individual's walking ability is not expected to improve. Documentation must support the medical necessity and expected benefit.
Provider supervision solely to oversee repetitive walk‑strengthening exercises for feeble or unstable patients is not considered medically necessary. Clinical documentation should justify therapist supervision when gait training is intended to produce measurable improvement in walking ability; otherwise supervision of repetitive walking tasks without demonstrated expectation of improvement may be non‑covered.
Systematic reviews and consensus statements do not support routine, stand‑alone use of McConnell patellar taping as a first‑line therapy for anterior knee pain. Evidence is heterogeneous and inconclusive; patellar taping may have a role as an adjunct within a multimodal program targeted to individual patient presentations, but routine solitary use is not supported by current evidence.
Hivamat (deep oscillation) therapy is supported primarily by small, uncontrolled studies and case series reporting symptomatic improvements; methodological limitations (small sample size, retrospective or uncontrolled design, and concomitant usual care) preclude firm conclusions. Therefore Hivamat/deep oscillation therapy is considered experimental/investigational pending higher‑quality randomized controlled trial evidence.
In a retrospective chart review of pediatric anterior hip pain, adding manual therapy to physical therapy did not improve pain efficiency and was associated with a greater number of visits. While manual therapy appeared safe, lack of demonstrated additional benefit and increased utilization indicate routine addition without supporting documentation may not be appropriate.
The policy notes that Postural Restoration and Muscle Activation Techniques (MAT) lack published data demonstrating clinical value. Because evidence is lacking, these modalities are not established as effective and should not be routinely covered absent compelling supporting documentation.
While VR/AR interventions have shown promise in improving short‑term gait and balance outcomes, available trials generally report only short‑term assessments and suffer from heterogeneity and risk of bias; therefore long‑term effectiveness and durability of VRBT remain insufficiently established for routine long‑term coverage without well‑designed trials demonstrating sustained benefit.
Coding and Billing
| 97010 | Application of a modality to 1 or more areas; hot or cold packs. |
| 97012 | Traction, mechanical. |
| 97014 | Electrical stimulation (unattended). |
| 97016 | Vasopneumatic devices. |
| 97018 | Paraffin bath. |
| 97022 | Whirlpool. |
| 97024 | Diathermy (eg, microwave). |
| 97026 | Infrared. |
| 97028 | Ultraviolet. |
| 97032 | Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes. |
| 97530 | Therapeutic activities — noted as not covered for Dynamic Movement Intervention. |
| no specific code | Kinesio taping, McConnell taping (not separately coded) |
| no specific code | Low dye strapping / strapping of the chest (no specific code) |
| no specific code | Dynatronics ThermoStim probe (no specific code) |
| M16.0 - M16.9 | Osteoarthritis of hip (ICD-10) — listed as not covered for indications in the CPB. |
| M25.551 - M25.559 | Pain in hip (ICD-10) — listed as not covered for indications in the CPB. |
| M84.361A - M84.369S | Stress fracture, tibia and fibula — listed as not covered for indications in the CPB. |
| M84.371A - M84.373S | Stress fracture, ankle — listed as not covered for indications in the CPB. |
| R10.2 | Pelvic and perineal pain [groin pain] — listed as not covered for indications in the CPB. |
| R29.3 | Abnormal posture — listed as not covered for indications in the CPB. |
| No codes listed |
Provider Responsibilities, Prior Authorization, and Documentation
Benefit-period / Prior Authorization Note
Benefit-period / prior authorization: Some Aetna plans (e.g., HMO, QPOS, Health Network Only/Option) limit short-term physical therapy benefits to a 60‑day treatment period or to a specified number of sessions (may be calendar-year, contract-year, or lifetime‑based in some designs). Check the member's benefit plan description for applicable limits and prior authorization requirements before initiating care.
- Typical Aetna HMO treatment-period limit: 60 days per condition
- Some plans define benefit by number of sessions per year
- Verify plan-specific prior authorization rules and benefit limits
Prosthetic / Orthotic Assessments
Prosthetic/orthotic assessments: Assessments (including prosthetic checkout and orthotic assessment) are considered medically necessary when a device is newly issued, modified, re‑issued, or when the member experiences device‑related loss of function (e.g., pain, skin breakdown, falls). Typically no more than ~30 minutes of time is necessary for these assessments.
- Medically necessary for new device, modification, re‑issue, or device‑related functional loss
- Usual time: ≤ 30 minutes
Prior Authorization Recommended for Hands‑Free Ultrasound
Hands‑free ultrasound: Prior authorization is recommended/appropriate for hands‑free ultrasound delivery. Clinical evidence shows hands‑free devices may produce significantly less therapeutic tissue heating than manual ultrasound and CMS has deemed hands‑free delivery investigational.
- Study (Gulick 2010): hands‑free US produced less tissue heating at 1‑ and 2‑cm depths versus manual transducer
- CMS considers hands‑free ultrasound investigational — consider prior authorization or exclusion
Prior Authorization Likely for Investigational Modalities
Investigational modalities: Prior authorization is likely for interventions described as investigational or experimental (for example, hands‑free ultrasound, Hivamat/deep oscillation therapy, and other emerging modalities) because available evidence is limited or inconsistent.
- Hivamat / deep oscillation therapy: small uncontrolled studies with methodological limitations
- Hands‑free ultrasound: inconsistent therapeutic heating data
Prior Authorization — Evidence Summary
Prior authorization — evidence summary only: The prior authorization considerations above are supported by the cited evidence summaries (e.g., hands‑free ultrasound heating study and small uncontrolled Hivamat reports). This section summarizes clinical evidence and does not, by itself, specify the exact CPT/HCPCS codes that require prior authorization.
- Evidence summaries inform prior authorization decisions but do not list per‑code authorization rules in this excerpt
Prior Authorization Guidance
Prior authorization guidance: When in doubt, consult the member's benefit plan description and follow standard prior authorization procedures. Use the written plan‑of‑care elements (diagnosis, onset date, measurable goals, frequency/duration, techniques, physician and therapist signatures) to substantiate requests for authorization and continuation of therapy.
- Provide ongoing, written plan of care with objective measures and progress notes
- Reevaluate at least monthly and document measurable improvement toward goals
Denial Risk — Not Medically Necessary Conditions
Denial risk conditions: Physical therapy is considered not medically necessary (and may be denied) when provided to asymptomatic individuals, persons without an identifiable clinical condition, or when the member's condition is neither improving nor regressing. Also not medically necessary once therapeutic benefit has been achieved or when a home exercise program is appropriate instead of continued supervised PT.
- Asymptomatic persons or no identifiable clinical condition: not medically necessary
- No documented improvement or regression: not medically necessary
- Continued supervised PT after therapeutic benefit / when a home program suffices: not medically necessary
Gait Training — Medical Necessity and Limitations
Gait training: Gait training is medically necessary when a member's walking ability is impaired due to neurologic, muscular, or skeletal conditions and improvement is reasonably expected. Gait training is not considered medically necessary when the individual's walking ability is not expected to improve. Supervision of repetitive walk‑strengthening exercise for feeble or unstable patients (without expectation of functional improvement) is not medically necessary. Gait training is not appropriate for relatively normal individuals with minor or transient gait abnormalities.
- Medically necessary when walking impairment exists and improvement expected
- Not medically necessary if improvement is not expected or for minor/transient gait issues
- Provider supervision of repetitive walking exercise alone is not generally necessary
Do Not Perform or Bill Duplicative Modalities/Services
Avoid duplicative modalities/services in the same session: Certain modalities and therapeutic services are considered duplicative and it is inappropriate to perform or bill both during the same session. Documentation must support the medical necessity and distinction of services when multiple therapies are provided on the same day.
- Examples of duplicative pairs: Functional activities and ADL; Infrared and ultraviolet; Massage therapy and myofascial release; Microwave and infrared; Orthotics training and prosthetic training; Whirlpool and Hubbard tank
- Only one superficial heat modality per session is medically necessary; ultrasound may be combined with one superficial heat modality but not with other deep heat modalities
- Medical record must document distinct services/goals when related trainings (e.g., prosthetic training and gait training) occur on same date
Hands‑Free Ultrasound — Investigational Heating Findings
Hands‑free ultrasound — investigational heating: Clinical data indicate hands‑free ultrasound devices produced significantly less tissue heating than manual ultrasound (example: Gulick 2010), and a therapeutic level of heating was not achieved at 2‑cm depth with the hands‑free device. This finding raises effectiveness concerns and supports cautious coverage decisions.
- Gulick (2010): manual US increased temperature more than hands‑free at 1‑ and 2‑cm depths
- Therapeutic heating not achieved at 2‑cm with hands‑free device
Potential Denial Risk When Benefit Not Demonstrated
Potential denial risk when benefit not demonstrated: Interventions lacking demonstrated clinical benefit or associated with increased utilization without improved outcomes (for example, manual therapy in certain pediatric anterior hip pain series) may be subject to denial or utilization management. Ensure documentation shows measurable improvement and reasonable expectation of benefit.
- Example: retrospective data showed manual therapy did not improve pain efficiency and increased visits in pediatric anterior hip pain — consider denial if benefit not shown
- Document objective improvement and progress toward plan‑of‑care goals to support continued therapy
Not Applicable — Step‑Therapy Content
Not applicable/No step‑therapy in this segment: There are no specific step‑therapy requirements specified in these excerpts. When step‑therapy or conservative care pathways are part of a plan design (e.g., trial of structured PT before surgery), follow the member's benefit rules and document compliance.
- Example step‑therapy approach (plan‑level): structured PT (e.g., 8 weeks / 16 sessions focused on strength/coordination) may be required prior to arthroscopic partial meniscectomy in selected patients
- Consult plan documents for any mandatory conservative care requirements
Documentation: Distinct Treatments, Timing, and Outcome Measures
Document distinct treatments and timing: When orthotic or prosthetic training occurs on the same date as gait training or self‑care/home management training, the medical record must document distinct treatments, separate goals, and time spent for each service. For taping and other adjunctive modalities, document timing of outcome measurement and the measures used to assess effect.
- Document separate goals and services when prosthetic training and gait training are on same visit
- For taping: document timing of outcome measures (e.g., immediate, 24‑hr) and specific pain/ROM scales used
Documentation Guidance — Myofascial Physical Therapy Trials
Documentation for myofascial PT trials: RCTs and feasibility studies of myofascial physical therapy report treatment schedules (commonly up to 10 weekly 1‑hour sessions) and adherence monitoring. When using myofascial PT, include protocol adherence, session frequency/duration, and patient response in the record to support medical necessity.
- Fitzgerald et al (2013): up to 10 weekly 1‑hour treatments in feasibility RCT
- Document therapist adherence to protocol, adverse events, and patient global response
No Modality‑Specific Documentation Listed Here — Use Standard Plan‑of‑Care Elements
No specific documentation requirements for every modality in these excerpts: While many modalities lack modality‑specific documentation rules in this excerpt, standard plan‑of‑care documentation elements remain required (diagnosis with onset date, measurable goals, frequency/duration, specific techniques, signatures, and regular reevaluation).
- Use the Appendix plan‑of‑care elements to substantiate medical necessity for any modality
- Reevaluate at least monthly and document progress toward goals
Taping — Adjunctive Role and Documentation
Taping as adjunctive therapy: Taping (e.g., Kinesio or patellar taping) may provide short‑term symptom relief in some conditions but is generally considered an adjunct rather than sole therapy. For patellofemoral pain and other conditions, require documentation that taping is provided in combination with other evidence‑based treatments and document targeted, individualized application.
- Taping may improve short‑term pain/ROM but clinical significance may be small
- Document combination with other PT interventions and individualized application
Conservative Progression — Spine Therapy Documentation
Conservative progression before specialized spine therapies: For spine‑related care, document a structured progression from advice/education to exercise and then to specialized methods (e.g., McKenzie) as clinically appropriate. Include baseline disability/pain measures (ODI, RM, VAS), classification method used (e.g., McKenzie MK or MK‑C), and prior conservative care in records.
- Document baseline measures (ODI, Roland‑Morris, VAS) and the classification system used
- Record prior conservative treatments and rationale for advancing to specialized therapies
Step‑Therapy Example: Structured PT Trial Before Arthroscopy
Step‑therapy example — PT before arthroscopy: Evidence supports that a structured trial of PT (e.g., 8 weeks / 16 supervised sessions focused on coordination and strength) can be a non‑surgical alternative for many patients with non‑obstructive meniscal tears. Consider requiring documentation of a supervised PT trial before elective arthroscopy when plan design or utilization management protocols specify this pathway.
- van de Graaf et al (2018): PT protocol (16 sessions over 8 weeks) was non‑inferior to arthroscopic partial meniscectomy for non‑obstructive meniscal tears
- Document adherence to PT protocol and clinical response if using PT trial as a prerequisite
Meniscal Tear Trial — PT as a Supported Non‑Surgical Alternative
Meniscal tear trial supports non‑surgical PT alternative: The randomized trial of PT versus arthroscopic partial meniscectomy showed PT can be an effective alternative for many patients with non‑obstructive meniscal tears; incorporate this evidence when evaluating surgical necessity and prior authorization requests.
- PT group improved substantially and met non‑inferiority criteria over 24 months
- Use documented PT trial outcomes to inform surgical authorization decisions
Definitions and Key Terms
Physical therapy is a prescribed program of modalities, therapeutic procedures, and exercises intended to relieve symptoms, improve function, and prevent disability from disease or injury. Medically necessary PT must be restorative or directed to designing/teaching a maintenance program, relate to a written treatment plan, and require the skills of a qualified physical therapist. Maintenance care is intended to preserve current function once therapeutic goals are achieved or a plateau is reached (a plateau is often defined as about 4 weeks when no further significant progress is expected).
Clinical Evidence and Background
Modality-specific evidence summaries
Findings summarized from cited studies — coverage stance depends on strength of evidence and investigational status.
Claims relying on therapeutic effect at depth may be unsupported
Considered experimental/investigational pending higher-quality RCTs
May be considered selectively with documentation
Coverage may consider short-term use with documented goals and progress
Evidence-linked coverage considerations
Coverage-relevant evidence summaries
Trials cited include Clare et al, Machado et al, and Petersen et al; clinical documentation of classification method and baseline measures recommended.
~29% of PT group crossed over to APM during follow-up; documentation of PT protocol and outcomes recommended.
The absence of McKenzie exercises or Mechanical Diagnosis and Therapy in an UpToDate palliative care review indicates that MDT is not specifically recommended in palliative care settings according to that source; this should be considered when proposing MDT for palliative patients and documented accordingly.
UpToDate topic reviews on stress fractures and on approaches to hip pain do not list strapping as a recommended management option. This lack of mention implies strapping is not a standard, evidence‑based therapy for ankle stress fractures or for unspecified hip pain in those reviews.
Systematic reviews of VR‑based rehabilitation note short‑term improvements but emphasize that included studies provide assessments only at short follow‑up, are heterogeneous, and frequently have a moderate risk of bias; accordingly, evidence for medium‑ and long‑term effects of VRBT is insufficient to support durable benefit claims.
Policy Revision History
Policy originally became effective.
Most recent clinical policy review completed.
Next policy review is scheduled.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.