CurrentAetnaPolicy 0325

Physical Therapy

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.

Policy Summary

PayerAetna

PolicyPhysical Therapy

Policy CodePolicy 0325

Change TypeNo material change

Effective DateJul 20, 1999

Next Review DateMar 28, 2024

Key ActionEnsure an ongoing, written plan of care with objective measures and measurable goals is maintained and reviewed by the treating physician before and during therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60-daytreatment-period limit in some plans

12 visits/4 wksADL training typical course

12–18 visitsstandard course — neuromuscular reeducation

multiplelisted investigational interventions

>=40 sessionsVRBT dose for functional balance (MS)

07/28/2023

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Coverage Criteria and Clinical Policy

Initial medical necessity

Covered when ALL of the following are met:

Primary medical necessity criteria: 1) PT is prescribed by an authorized practitioner (e.g., chiropractor, DO, MD, NP, podiatrist or other qualified professional) to significantly improve, develop or restore physical function lost or impaired due to disease, injury or surgery; AND 2) The treating clinician has determined the member's condition can improve significantly based on objective physical measures (e.g., AROM, strength, function, pain) within one month of therapy start or the services are necessary to establish a safe, effective maintenance program that the member can perform without ongoing skilled therapy; AND 3) Services are ordered by a physician or other licensed practitioner and performed by a duly licensed/certified PT provider within scope of practice; AND 4) Services are of a complexity and nature that require performance by a licensed professional therapist or under their direct supervision as permitted by state law.

From policy medical necessity section

Limitations and maintenance

Also required/considered:

Required plan-of-care and goals: PT must be provided in accordance with an ongoing, written plan of care that is reviewed with and approved by the treating physician and include sufficient objective and subjective data to demonstrate medical necessity (diagnosis with onset date, estimated time to reach goals, specific measurable long- and short-term goals, PT evaluation, frequency/duration, treatment techniques, and signatures).

Plan-of-care documentation requirement (see Appendix)

Not medically necessary conditions: PT is not medically necessary for asymptomatic persons or persons without an identifiable clinical condition; when the condition is neither regressing nor improving; or continuing supervised PT once therapeutic benefit achieved or a home exercise program would suffice. Gait training is not medically necessary when walking ability is not expected to improve; supervision of repetitive walk-strengthening exercise for feeble or unstable patients is not considered medically necessary.

Exclusions and NMN statements

Maintenance care is intended to preserve current function when therapeutic goals are achieved or a plateau reached; routine/repetitive services that can be provided by non-skilled personnel are not covered as skilled PT.plateau = 4 weeks

Maintenance care definition and implication

Experimental / Investigational

The following interventions are considered experimental/investigational (not an all-inclusive list):

Experimental interventions list: Adhesion removal physical therapy for bowel obstructions; Applied Functional Science; Dynamic Movement Intervention (DMI); Kinesio taping, McConnell taping, and other taping techniques for multiple indications; hands-free ultrasound and low-frequency sound (infrasound); Hivamat (deep oscillation) therapy; Interactive Metronome program; Low‑dye strapping for ankle stress fracture; MEDEK therapy; strapping of chest/hip for posture/pain; ultrasound for Dupuytren's contracture; virtual reality–facilitated gait training (long-term effectiveness not established).

Listed experimental/investigational interventions

Gait Training

Covered when ALL of the following are met

Gait training criteria: Gait training is medically necessary for individuals whose walking abilities have been impaired by neurological, muscular or skeletal abnormalities or trauma and when walking ability is expected to improve.

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

Neuromuscular re-education criteria: Provided to improve balance, coordination, posture, proprioception, or recovery from muscle paralysis affecting the neuromuscular system (examples: poor static/dynamic balance, loss of gross/fine motor coordination, hypo/hypertonicity) resulting from disease or injury; requires skilled therapist involvement.Standard treatment 12 to 18 visits within a 4- to 6-week period

Ultrasound

Covered when ALL of the following are met

Ultrasound criteria: Therapeutic ultrasound is considered medically necessary for selected musculoskeletal indications (eg, arthritis, inflammation of periarticular structures, neuromas, softening adhesive scars) when documented in the plan of care and delivered by qualified personnel.Standard treatment 3 to 4 treatments per week for 1 month

Ultrasound is considered experimental/investigational for asthma, bronchitis, other pulmonary conditions, and Dupuytren's contracture.

Modalities and Duplicative Services

Coverage stance and limitations

Heat modalities: Only one superficial heat modality is considered medically necessary during the same treatment session. Ultrasound (deep heat) may be used with one superficial heat modality but not with other deep heat modalities.

Duplicative modalities: It is inappropriate to perform or bill for duplicative physical medicine modalities or therapeutic services during the same session (examples: functional activities and ADL; infrared and ultraviolet; massage therapy and myofascial release; microwave and infrared; orthotics training and prosthetic training; whirlpool and Hubbard tank). Medical necessity of multiple therapies on the same day must be documented.

Orthotic/Prosthetic Training and Checkout

Covered when ALL of the following are met

Prosthetic/orthotic checkout: Assessments (checkout) are medically necessary when a device is newly issued or modified, or when the member experiences loss of function related to the device (eg, pain, skin breakdown, falls).Usually no more than 30 minutes

Training: Orthotic and prosthetic training is medically necessary for persons who meet criteria for a brace/splint or have a medically necessary prosthetic; distinct goals and services must be documented when performed the same day as gait or self-care training.It is unusual to require more than 30 minutes of prosthetic/orthotic training on a given date.

Periodic revisits beyond 3 months may be reviewed for medical necessity.

Augmented Soft Tissue Mobilization (ASTM) and ThermoStim Probe

Coverage stance

ASTM: Augmented soft tissue mobilization (ASTM) uses hand-held tools to scrape/mobilize scar or fibrotic tissue; evidence is insufficient to support its effectiveness.

Typical treatment frequency 1–2 times/week; sessions often ~30 minutes including exercise.

ThermoStim Probe: No data demonstrate that the ThermoStim probe provides effective soft tissue mobilization or intramuscular heating comparable to standard moist hot pack; neither achieved the 3–4°C rise associated with increased tissue extensibility in a cited study.

ThermoStim allows electrical stimulation which is covered under electrical stimulation policy when applicable.

Interactive Metronome (IM)

Coverage stance

IM program: Interactive Metronome (IM) program is promoted for processing speed, focus and coordination and has been applied to ADHD and other disorders, but existing studies are mixed and overall evidence is insufficient to support effectiveness; randomized controlled trials are needed.

Small case series and limited studies report selective improvements but are not conclusive.

Kinesio / McConnell / Taping

Coverage stance

Taping: Kinesio and McConnell taping methods are used in rehabilitation and sports medicine; evidence is mixed—some small trials show immediate or short-term improvements in select measures (eg, pain, ROM) but overall effectiveness and long-term benefit as standalone therapies have not been established.

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

Taping role: Patellar taping and bracing may play a role in patellofemoral pain management as part of combined interventions, but their role in isolation is not clearly established and they are not confirmed as first-line treatments.

Consensus statement: consider adjunctive use and individualization of taping approach.

McConnell taping — evidence insufficient

Review conclusion regarding McConnell taping

McConnell taping: Systematic review evidence is insufficient to justify routine use of McConnell taping for anterior knee pain; pooled biomechanical outcomes showed no significant differences and more high-quality trials are needed.

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

Hands-free ultrasound produced significantly less tissue heating than manual handheld ultrasound at 1-cm and especially at 2-cm depth in a cited study; therapeutic heating at deeper tissues was not achieved, and CMS has deemed hands-free delivery investigational.therapeutic tissue heating not achieved at 2-cm

May be considered investigational/unproven for therapeutic ultrasound delivery.

Kinesio taping — limited short-term evidence

Kinesio taping evidence

Kinesio taping outcomes: Some randomized and controlled studies report immediate or short-term improvements in pain and range of motion (eg, acute whiplash, shoulder impingement), but effects are often small, of uncertain clinical significance, limited by small sample sizes, and long-term benefit is unclear.

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.

Hands-free ultrasound: Evidence shows hands-free ultrasound produced significantly less tissue heating than manual handheld ultrasound (3 MHz), particularly at 2-cm depth; CMS has deemed hands-free delivery investigational and therapeutic heating at depth was not achieved.therapeutic heating not achieved at 2-cm

May be considered investigational/unproven for therapeutic ultrasound delivery

Hivamat (deep oscillation) therapy: Small uncontrolled series report symptom improvements (eg, VAS reductions, physician-rated benefits) but evidence is limited by small size, retrospective/uncontrolled design, and concomitant usual care.evidence limited to small uncontrolled series

Considered experimental/investigational pending higher-quality RCTs

Applied Functional Science (AFS) is proposed as an integrative framework but lacks evidence of clinical value in the cited literature.

Evidence-linked coverage considerations

Coverage-relevant evidence summaries

Acute low back pain (MDT evidence): Systematic reviews and meta-analyses reported McKenzie (MDT) provides greater short-term reductions in pain and disability compared with passive therapies; magnitude may be small and long-term effects uncertain.short-term follow-up (<=3 months)

Clare et al and Machado et al reported short-term benefits; long-term effects uncertain.

Chronic low back pain (classification-based MDT): Evidence is limited and mixed; some trials suggest benefit over manipulation or certain comparators, but overall long-term superiority and validity of classification remain unestablished.chronic LBP cohorts

Petersen (2015) found McKenzie superior to manipulation across subgroups but further study needed.

Extremity/other conditions: Case reports and small trials suggest MDT methods may help some extremity derangements, but high-quality evidence is limited and applicability is uncertain.

APM versus physical therapy (non-obstructive meniscal tears)

Findings relevant to coverage decisions — evidence-based comparisons

Meniscal tear treatment evidence: Randomized multicenter trial (n=321) reported PT non-inferior to arthroscopic partial meniscectomy for non-obstructive meniscal tears over 24 months; PT protocol consisted of 16 sessions over 8 weeks focused on coordination and closed-kinetic chain strength exercises; results support considering structured PT as an alternative to immediate APM.non-inferiority margin 8 points on IKDC

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

Hip-targeted PT systematic review: Systematic review of 6 RCTs (n=387) found trivial effect on pain and small effect on disability for hip-targeted PT in patients with low back pain; included studies had high risk of bias and authors concluded no statistically significant reductions in pain or disability.

Evidence judged high risk of bias.

Post-hip fracture home PT

Home-based multi-component PT trial: RCT (n=210) comparing multi-component home PT vs active control (TENS + AROM) found no statistically significant difference in the primary outcome (community ambulation — walking ≥300 m in 6 minutes at 16 weeks).community ambulation = 300 m in 6 mins

Both groups received home visits; adverse events reported.

Myofascial PT for CPPS

Myofascial physical therapy for chronic pelvic pain syndrome (CPPS)

Myofascial PT evidence: Feasibility RCT and pilot studies report potential benefit (eg, feasibility RCT showed global response 57% for myofascial PT vs 21% for global therapeutic massage); sample sizes were small and authors call for larger RCTs — evidence considered preliminary.

Evidence insufficient for broad coverage conclusions; may be considered where clinical judgment supports use.

Modalities lacking evidence

Insufficient evidence modalities: Postural restoration and Muscle Activation Techniques (MAT) are described but there is a lack of published data on clinical value or effectiveness; these modalities lack sufficient evidence to support routine use.

Listed as lacking evidence in document.

Virtual reality gait training

Virtual reality (VR) facilitated gait training

VR-based gait/balance rehabilitation: Systematic reviews report VR interventions can improve gait and balance in neurologic populations, particularly when combined with conventional rehabilitation; however, many studies have poor methodological quality and heterogeneous protocols — larger, rigorous RCTs and better reporting of therapist role and intervention details are needed.

Adverse events (eg, dizziness) reported in some trials; therapist role and intervention details should be documented.

Physiotherapy and BDNF

PT effects on biomarkers

BDNF and PT: Systematic review (7 studies) found moderate evidence that rTMS and intramuscular electrical stimulation increased BDNF and reduced pain in chronic myofascial pain; other PT modalities showed low evidence for affecting BDNF or pain compared to placebo or minimal intervention — conclusions are limited and further study is needed.

Covered with documentation and clinician judgement

General coverage considerations for VR/AR gait training: VR/AR gait training may be considered when integrated into an ongoing, written plan of care that documents diagnosis, onset date, measurable goals, evaluation, frequency/duration, specific techniques, and appropriate physician/PT signatures, and when there is reasonable expectation of measurable improvement in a reasonable period.

Plan-of-care documentation required; see documentation module for specifics.

Evidence-based potential indications: VR/AR interventions have demonstrated improvements in gait and balance in Parkinson disease and functional/dynamic balance in multiple sclerosis; interventions are more effective when adjunctive to conventional therapy and tailored to rehabilitation goals.

Evidence limited by heterogeneity, small samples, and risk of bias.

Dose-response considerations (MS evidence): For people with MS, the most adequate dose to improve functional balance in trials was at least 40 sessions (5 sessions/week, 40–45 minutes/session); for dynamic balance, 8–19 weeks twice-weekly 20–30 minutes/session was reported.

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

Covered CPT Codes (if selection criteria are met)mixedCovered

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.

1–10 of 47

1/5

CPT/HCPCS codes not covered for listed indications / no specific code itemsmixedNot Covered

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)

ICD-10 codes not covered for indications listed in CPBICD-10Not Covered

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 explicit CPT/HCPCS/ICD-10 codes in these excerptsmixed

No codes listed

inv-45: ADL training typical course

Typical courseStandard medical treatment may generally require up to 12 visits in 4 weeks for ADL training

IndicationsTraining of severely impaired individuals in essential ADLs (bathing, feeding, toileting, transferring, walking) when requires professional skills and part of active treatment plan

Patient capacityMember must have capacity to learn from instruction

Concurrent servicesServices provided concurrently by physicians, PTs and OTs may be medically necessary if separate and distinct functional goals are documented

inv-46: Maintenance plateau definition

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

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

Documentation Required

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.

Definitions and Key Terms

inv-84: Maintenance care

DefinitionActivities intended to preserve the patient’s present level of function and/or prevent regression; begins when therapeutic goals are achieved or when no further significant progress is expected

InitiationMaintenance begins when therapeutic goals achieved or when a plateau is reached

Coverage noteMaintenance services that are routine/repetitive and can be furnished by non‑skilled personnel are not covered as skilled PT

Relation to planMust relate to a written treatment plan; medically necessary PT must be restorative or for designing/teaching a maintenance program

inv-85: Qualified physical therapist / PTA

Qualified PTA person licensed as a physical therapist by the state in which they practice

Clinical Evidence and Background

Modality-specific evidence summaries

Findings summarized from cited studies — coverage stance depends on strength of evidence and investigational status.

Hands-free ultrasound produced significantly less tissue heating than manual handheld ultrasound at measured depths in a cited study; therapeutic heating at 2-cm depth was not achieved, and CMS has deemed hands-free delivery investigational — this finding affects coverage considerations for hands-free devices.therapeutic heating not achieved at 2-cm

Claims relying on therapeutic effect at depth may be unsupported

Hivamat (deep oscillation) therapy: Available evidence is limited to small, retrospective or uncontrolled series reporting symptom improvements; quality is insufficient to establish routine clinical effectiveness.evidence limited to small uncontrolled series

Considered experimental/investigational pending higher-quality RCTs

Policy Revision History

1999-07-20Effective date

Policy originally became effective.

2023-07-28Last reviewLatest

Most recent clinical policy review completed.

2024-03-28Next scheduled review

Next policy review is scheduled.

Policy Summary

PayerAetna

PolicyPhysical Therapy

Policy CodePolicy 0325

Change TypeNo material change

Effective DateJul 20, 1999

Next Review DateMar 28, 2024

Key ActionEnsure an ongoing, written plan of care with objective measures and measurable goals is maintained and reviewed by the treating physician before and during therapy.

SourceLink

On This Page

insufficient evidence

Not supported by current literature in these sections

Myofascial PT for pelvic pain: A feasibility RCT (n=48) showed higher global response rates for myofascial physical therapy versus global therapeutic massage (57% vs 21%); findings are preliminary and warrant larger RCTs.evidence preliminary from feasibility RCT

May be considered where clinical judgment supports use; evidence limited

McKenzie Method for spinal pain: Systematic reviews/meta-analyses found McKenzie therapy provided greater short-term reductions in pain and disability versus comparators for low back pain, but long-term effects and superiority remain uncertain.short-term benefit demonstrated

May be supported for short-term symptom relief; further evidence needed for long-term benefit

Evidence for extremity applications is sparse.

PT versus surgery (knee meniscal tears): A multicenter RCT (n=321) found structured PT (16 sessions over 8 weeks) was non-inferior to arthroscopic partial meniscectomy for non-obstructive meniscal tears over 24 months; PT may be considered an alternative to immediate surgery.non-inferiority margin 8 points on IKDC over 24 months

~29% of PT group crossed over to surgery during follow-up.

Derived from meta-analysis of 19 RCTs.

Therapist role and delivery: When VR/AR interventions are used, therapist involvement in selection, tailoring, supervision, and safeguarding should be documented; incomplete intervention descriptions in studies limit replication.

Document therapist role and rationale.

A plateau is a period of four weeks (or, depending on condition/patient, a lesser period) when no further significant progress is seen

When maintenance beginsMaintenance begins when therapeutic goals are achieved or when no further significant progress is reasonably expected

Coverage implicationMaintenance services that are routine/repetitive and can be provided by non‑skilled personnel are not covered as skilled PT

Examples of non‑skilled servicesPassive ROM and routine, repetitive procedures after initial teaching are considered non‑skilled

inv-47: Community ambulation threshold (6MWT)

Community ambulation thresholdDefined as walking 300 m or more in 6 minutes on the 6-minute walk test (6MWT)

Context of useUsed as the primary outcome (community ambulation) in a post‑hip fracture home PT randomized trial assessed at 16 weeks

Assessment timingMeasured at 16 weeks after randomization in the cited trial

inv-48: VRBT dose for functional balance

Recommended dose for functional balance (PwMS)At least 40 sessions delivered as 5 sessions/week with 40–45 minutes per session

Evidence sourceDerived from a meta-analysis of 19 RCTs including 858 persons with MS

Expected effectAssociated with greatest improvement in functional balance in persons with MS

inv-49: VRBT dose for dynamic balance

Recommended dose for dynamic balance8–19 weeks, twice-weekly sessions of 20–30 minutes each

PopulationReported in meta-analysis of VR-based therapy trials in persons with MS

Outcome targetedImprovements in dynamic balance and postural control

Medically necessary for new device, modification, re‑issue, or device‑related functional loss
Usual time: ≤ 30 minutes

Prior Authorization

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

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

Note

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

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

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

Denial Risk

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

Billing Rule

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

Note

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

Denial Risk

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

Step 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 Required

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 Required

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

Documentation Required

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

Documentation Required

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

Documentation Required

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

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

Note

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

PTAA physical therapist assistant (PTA) must be licensed where applicable and services must be supervised by a licensed PT at a level determined by state law/regulation

Scope of servicesPTA services cannot be provided as incidental to a physician; PT services must require the skills of a qualified PT or under appropriate supervision

inv-86: Dynamic Movement Intervention (DMI)

DefinitionDynamic Movement Intervention (DMI) is a pediatric intervention provoking specified active motor responses via defined dynamic exercises to improve automatic postural responses and promote developmental milestones

Target populationChildren with gross motor impairments (e.g., cerebral palsy, developmental motor delay)

Evidence noteThere is a lack of evidence regarding the effectiveness of DMI therapy

inv-87: Interactive Metronome (IM)

DefinitionInteractive Metronome (IM) uses auditory metronome cues with sensor feedback to train timing, processing speed, focus, and coordination

ApplicationsPromoted for ADHD, special needs children, balance disorders, stroke, amputation, MS, Parkinson disease, and TBI

Evidence noteExisting studies show mixed results and overall evidence is insufficient to support effectiveness for many indications

inv-88: Augmented Soft Tissue Mobilization (ASTM)

DefinitionAugmented Soft Tissue Mobilization (ASTM) is a non-invasive technique using hand-held tools to scrape and mobilize scar or fibrotic tissue, often with lubricant and combined exercise

Treatment patternOften administered 1–2 times/week; typical 30‑min session includes ~15 mins treatment + 15 mins exercise; less severe cases 2–4 sessions, chronic cases 8–16 sessions

Evidence noteThere is insufficient evidence to support effectiveness

inv-89: MEDEK

DefinitionMEDEK (Metodo Dinamico de Estimulacion Kinesica) is a dynamic method for kinetic stimulation focusing on training postural/functional tasks to develop gross motor skills in children with disabilities

PrinciplesTrains movements leading to sitting, standing and walking; tasks performed without child’s attention/cooperation to provoke automatic postural reactions

Evidence noteWell‑designed clinical studies are needed to ascertain effectiveness

inv-90: Hands-free ultrasound

DefinitionHands‑free ultrasound: an ultrasound delivery mode using a stationary transducer/device that pulses the ultrasound beam allowing unattended application rather than continuous clinician-held scanning

Device comparisonHands‑free device pulses the beam through a fixed transducer and is compared against manual hand‑held transducer for tissue heating

Regulatory noteCMS has deemed delivery of US via hands‑free unit investigational

inv-91: Hands-free ultrasound — alternate phrasing

Alternate phrasingA hands‑free ultrasound device uses a fixed transducer to deliver pulsed ultrasound allowing unattended application and differs from manual delivery by not providing continuous clinician scanning

Clinical findingHands‑free ultrasound produced significantly less tissue heating than manual ultrasound at 1‑cm and especially at 2‑cm depth in a study of 40 volunteers

Coverage implicationTherapeutic heating at deeper tissues was not achieved with the hands‑free device, raising questions about equivalence to manual ultrasound

inv-92: Hivamat (deep oscillation) therapy

DefinitionHivamat (deep oscillation) therapy uses an intermittent electrostatic field intended to create deep kneading effects in tissues to reduce edema, pain, and promote healing

Mechanism claimElectrostatic waves are said to penetrate deeper than manual methods producing a deep kneading effect

Evidence noteEvidence is limited and based on small, uncontrolled studies; further RCTs are needed

inv-93: McKenzie Method (Mechanical Diagnosis and Therapy)

DefinitionMcKenzie Method (Mechanical Diagnosis and Therapy) is a musculoskeletal classification‑based approach to assessment and treatment of spinal pain involving repeated movements and self‑treatment strategies

ApplicationInvolves repeated movements and classification-based management for spinal pain; used clinically for lumbar and cervical conditions

Evidence noteSystematic reviews/meta-analyses report short‑term reductions in pain and disability versus comparators, but long‑term effects and comparisons to placebo are insufficient

inv-94: MK-C

DefinitionMK‑C refers to McKenzie plus combined examination (MK‑C) — an expanded examination combining MK classification with additional tests

UtilityMK‑C reduced inconclusive classifications in a chronic LBP cohort and allowed classification in ~94% of patients in a cited study

inv-95: WMD

DefinitionWeighted mean difference (WMD) is the pooled difference on a 0–100 scale used to report pooled pain/disability effects in meta-analyses

ExampleUsed to report pooled pain and disability changes in Machado et al. meta-analysis of the McKenzie method

inv-96: Non-obstructive meniscal tear

DefinitionNon‑obstructive meniscal tear: a meniscal tear without locking of the knee joint; population enrolled in the APM vs PT trial (patients aged ~45–70 without instability/severe OA)

Study contextCited randomized multicenter trial (n=321) compared PT vs arthroscopic partial meniscectomy for non‑obstructive meniscal tears

inv-97: Community ambulation (trial outcome)

Trial definitionCommunity ambulation (trial outcome) was defined as walking 300 m or more in 6 minutes (6MWT) at 16 weeks after randomization in the hip fracture trial

UseServed as the primary outcome for community ambulation in the cited home‑based PT randomized clinical trial

inv-98: Movement visualization (MV)

DefinitionMovement visualization (MV) is the visual information depicting the user's movement within the virtual environment and is a key element of VR‑based rehabilitation interventions

RoleMV categorization (indirect, abstract, augmented reality, avatar, tracking, combined, none) affects how movement is displayed and may influence motor outcomes

inv-99: VR/AR rehabilitation interventions

DefinitionVR/AR rehabilitation interventions are therapist‑delivered or supervised therapies using virtual or augmented reality technologies to provide task‑specific, controlled, and engaging practice environments to promote motor learning and functional recovery

ScopeMay target gait, balance, upper extremity, posture and cognitive elements; often used adjunctively with conventional therapy

Delivery considerationsTherapist role, dosage, movement visualization, and customization should be documented; heterogeneity in reporting limits comparability across studies

inv-100: Clinical Policy Bulletins

DefinitionClinical Policy Bulletins are tools to assist in administering plan benefits and provide general descriptions of covered services but do not constitute a contract or guarantee of payment

DisclaimerSpecific coverage depends on the member's plan provisions; failure to follow plan provisions may affect coverage

Administrative useUsed to guide medical necessity determinations and plan administration; providers should consult plan‑specific documents for prior authorization requirements

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).

Myofascial PT for pelvic pain: Feasibility RCT (n=48) showed a higher response rate for myofascial physical therapy versus global therapeutic massage (57% vs 21%), but evidence remains preliminary and further larger RCTs are needed to support broad coverage decisions.evidence preliminary

May be considered selectively with documentation

McKenzie Method: Systematic reviews/meta-analyses demonstrate McKenzie method yields small short-term improvements in pain and disability for low back pain versus some comparators, but long-term superiority is not established and clinical significance may be limited.short-term benefit demonstrated

Coverage may consider short-term use with documented goals and progress

Evidence-linked coverage considerations

Coverage-relevant evidence summaries

McKenzie / MDT evidence summary: Systematic reviews and meta-analyses report McKenzie/MDT provides greater short-term reductions in pain and disability compared with passive therapies for low back pain, but the magnitude is small and long-term effects are uncertain; classification-based approaches require further validation.short-term follow-up (<=3 months)

Trials cited include Clare et al, Machado et al, and Petersen et al; clinical documentation of classification method and baseline measures recommended.

PT as alternative to surgery (meniscal tear): A multicenter RCT (n=321) found structured PT (16 sessions/8 weeks) non-inferior to arthroscopic partial meniscectomy for non-obstructive meniscal tears at 24 months, supporting consideration of a structured PT trial prior to immediate surgery in appropriate patients.PT protocol: 16 sessions over 8 weeks; non-inferiority margin 8 points on IKDC

~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.