CurrentAloha CarePolicy N/A

Physical Therapy and Occupational Therapy Coverage Criteria

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This policy governs medical necessity, coverage criteria, prior authorization, documentation, limitations, and coding guidance for physical therapy (PT) and occupational therapy (OT) services for Aloha Care members.

Policy Summary

PayerAloha Care

PolicyPhysical Therapy and Occupational Therapy Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 22, 2018

Last ReviewAug 22, 2019

Next Review DateAug 22, 2019

Key ActionObtain prior authorization when required and include an individualized written treatment plan with goals, frequency/duration, and documentation of member participation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial eval/re-eval PA not required

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CurrentAloha CarePolicy N/A

Physical Therapy and Occupational Therapy Coverage Criteria

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Policy Summary

PayerAloha Care

PolicyPhysical Therapy and Occupational Therapy Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 22, 2018

Last ReviewAug 22, 2019

Next Review DateAug 22, 2019

Key ActionObtain prior authorization when required and include an individualized written treatment plan with goals, frequency/duration, and documentation of member participation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial eval/re-eval PA not required

prior authorization exemption within 6 months

Up to 1 hourcovered per visit

Many codesprior authorization required

E-stim (swallowing)explicit non-covered modality

Retired 11/27/2020document status change

Coverage Criteria for Physical and Occupational Therapy

General medical necessity criteria

Covered when ALL of the following are met:

Provider order and qualifications: Therapy must be ordered by a physician or other licensed health care practitioner who has established the member's diagnosis and is qualified to prescribe physical therapy or occupational therapy within their scope of practice.

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Provider performing therapy: Therapy must be provided by a physical therapist or physical therapist assistant practicing within the scope of licensure and under the supervision of the physical therapist.

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Purpose of therapy: Therapies are ordered to improve, develop, or restore neurological and/or musculoskeletal functions lost or impaired due to disease, trauma, surgical procedures, congenital anomalies, or prior therapeutic intervention.

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Goal and expected improvement: Therapy is to achieve a specific diagnosis-related goal for a member who has a reasonable expectation of achieving significant improvement in a reasonable and predictable period of time. 'Significant' is defined as a measurable and meaningful increase in the patient's level of physical and functional abilities that can be attained with short-term therapy, usually within a three-month period (with measurable changes often within a month for some goals).improvement usually within ~3 months

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Measures of progress: Progress should be documented using appropriate measures such as active range of motion, strength, motor exam, and functional abilities for PT; and useful/purposeful activities, orthoses guidance, and functional skill assessment for OT.

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Home program: Therapy must include a home exercise/education program initiated at the first physical therapy visit with documentation of the member's participation and compliance.

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Visit frequency and duration: Frequency of visits must be appropriate to the member's condition and stage of healing; coverage is up to one hour per visit.<= 1 hour per visit

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The policy lists specific exclusions where physical therapy (PT) and occupational therapy (OT) are not covered. PT/OT is not covered when any other therapy is provided concurrently with the same interventions and treatment for the same purpose. The policy also excludes services provided for leisure activities (hobbies, sports, recreation), ongoing treatment solely to improve endurance or distance, general exercise programs for overall fitness, programs intended for diversion or general motivation, long-term therapy, therapy for developmental delay as defined in the document, and conditions considered routine educational, training, conditioning, or fitness.

This policy was formally retired on 11/27/2020. Providers and reviewers should note the retirement date when referencing this document for coverage determinations or historical review.

PT and OT are considered not medically necessary when the member’s condition demonstrates no improvement. Services are also not medically necessary if the member’s function is likely to improve through the member’s gradual return to normal activities without formal therapy. Denials may be appropriate when measurable, meaningful improvement is not documented in the clinical record.

Relevant Procedure and HCPCS/CPT Codes

Relevant CPT codes and descriptionsCPT

64550	Application of surface (transcutaneous) neurostimulator (eg, TENS unit)
90901	Biofeedback training by any modality
90911	Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry
92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals
92520	Laryngeal function studies (ie, aerodynamic testing and acoustic testing)
92521	Evaluation of speech fluency (eg, stuttering, cluttering)
92522	Evaluation of speech sound production
92523	Evaluation of speech sound production with evaluation of language comprehension and expression
92524	Behavioral and qualitative analysis of voice and resonance

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Covered CPT Codes (with PA flags)CPTCovered

97032	Application of a modality to 1 or more areas, each 15 minutes (e.g., electrical stimulation), PA Policy = Yes
97036	Whirlpool, each 15 minutes, PA Policy = Yes
97039	Unlisted modality (specify type and time if constant attendance), PA Policy = Yes
97110	Therapeutic procedure; therapeutic exercises, each 15 minutes, PA Policy = Yes
97112	Neuromuscular reeducation, each 15 minutes, PA Policy = Yes
97113	Aquatic therapy with therapeutic exercises, each 15 minutes, PA Policy = Yes
97116	Gait training, each 15 minutes, PA Policy = Yes
97124	Massage, each 15 minutes, PA Policy = Yes
97139	Unlisted therapeutic procedure (specify), PA Policy = Yes
97140	Manual therapy techniques, each 15 minutes, PA Policy = Yes

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Occupational therapy and assistive device assessment codesCPT | mixedCovered

Therapy activity codes (OT) unspecified	Occupational therapy evaluation and re-evaluation noted as No PA for initial evaluation within a 6-month period; multiple OT procedure descriptions listed with PA Policy = Yes (therapeutic activities, cognitive skills development, sensory integrative techniques, self-care/home management, community/work reintegration, wheelchair management, assistive technology assessment, orthotic/prosthetic training).
97542	Wheelchair management, each 15 minutes, PA Policy = Yes
97750	Physical performance test or measurement with written report, each 15 minutes, PA Policy = Yes
97762	Checkout for orthotic/prosthetic use, established patient, each 15 minutes, PA Policy = Yes

Unlisted/HCPCS codesCPT | HCPCSCovered

97799	Unlisted physical medicine/rehabilitation service or procedure, PA Policy = Yes
G0283	Electrical stimulation (unattended) to one or more areas for indications other than wound care, as part of a therapy plan of care, PA Policy = Yes
G0451	Development testing, with interpretation and report, per standardized instrument form, PA Policy = Yes

Expectation for improvement timeframe

Expectation for meaningful improvementSignificant improvement is expected within a reasonable and predictable period—usually within three months; some measurable improvement may be seen within one month for specific goals.

Definition of 'significant'A measurable and meaningful increase in the patient’s level of physical and functional abilities documented in the patient record and attainable with short-term therapy.

Timing detailTherapy should show reasonable expectation of achieving significant improvement within a month, with usual timeframe for 'short-term therapy' being within three months.

Measures of progress to documentActive range of motion, strength, motor exam, and functional abilities for PT; useful/ purposeful activities, orthoses guidance, and functional skills/deficits for OT.

Associated expectations for plan of care

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

Prior authorization: initial eval/re‑eval exempt within 6 months

Prior authorization is not required for the initial evaluation and re‑evaluation of PT and OT within a six‑month period in a benefit year; PA is also not required for one PT or OT treatment on the same day as the initial evaluation or re‑evaluation. Obtain PA when additional evaluations exceed the six‑month limit or for additional treatments after the initial evaluation/re‑evaluation. Speech therapy evaluation and treatment require PA.

No PA for initial evaluation and re‑evaluation within a 6‑month period in a benefit year
No PA for one PT/OT treatment on same day as initial evaluation/re‑evaluation
PA required when additional evaluations exceed the limit under III.A or for additional treatments after the initial evaluation/re‑evaluation
PA required for evaluation and treatment for speech therapy

Prior Authorization

PA required for many timed procedures and unlisted services

Many timed therapeutic procedure codes, certain occupational therapy activity codes, and unlisted/HCPCS services are marked 'PA Policy = Yes' in the coding tables and require prior authorization before services are rendered.

Clinical Background

Physical therapy aims to restore function by addressing impairments such as range of motion, strength, endurance, balance, coordination, flexibility, joint mobility, and pain to enable return to activities of daily living. Therapy interventions should be targeted to achieve a specific, diagnosis‑related goal with a reasonable expectation of significant improvement within a predictable period, and should include a documented home exercise/education program initiated at the first visit.

Definitions of PT and OT

inv-19: Physical therapy (PT) — definition and focus

DefinitionTreatment using therapeutic exercise and other interventions focused on range of motion, posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, and pain alleviation to regain functional activities of daily living.

Treatment elementsMay include active and passive modalities and a variety of techniques based on biomechanical and neurophysiological principles.

Primary focusRestore physical function and alleviate pain to enable performance of activities of daily living.

inv-20: Occupational therapy (OT) — definition and focus

DefinitionEvaluation and treatment of neuromusculoskeletal and psychological symptoms through task- or goal-directed activities to improve functional performance, including cognitive, perceptual, safety, and judgment training.

Scope

Policy Summary

PayerAloha Care

PolicyPhysical Therapy and Occupational Therapy Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 22, 2018

Last ReviewAug 22, 2019

Next Review DateAug 22, 2019

Key ActionObtain prior authorization when required and include an individualized written treatment plan with goals, frequency/duration, and documentation of member participation.

SourceLink

On This Page

Therapy must include a home exercise/education program initiated at the first PT visit with documentation of member participation and compliance.

Examples include 97032, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150
OT/assistive device assessment codes (eg, wheelchair management 97542; physical performance test 97750) are PA = Yes
Unlisted/HCPCS entries (eg, 97799, G0283, G0451) are PA = Yes

Documentation Required

Include required documentation with PA to avoid denial

Submit PA requests with complete documentation demonstrating medical necessity per policy; incomplete or missing required documentation may result in denial or delay.

Include individualized written treatment plan (see required fields in PA documentation block)
Obtain PA for codes flagged 'PA Policy = Yes' before billing

Denial Risk

Risk of denial if PA not obtained for PA‑flagged codes

Services billed without prior authorization when the code is marked 'PA Policy = Yes' are subject to denial.

Verify PA requirement in the coding tables before providing services
Do not assume PA exemption except for the initial evaluation/re‑evaluation within six months

Documentation Required

PA documentation: individualized written treatment plan and required details

Documentation submitted with a prior authorization must include an individualized, written treatment plan that contains specific required elements to demonstrate medical necessity.

Diagnosis, symptoms and findings documenting medical necessity
Date of onset or exacerbation
Specific, quantitative long‑term and short‑term goals (including transition to a home maintenance program)
Therapy evaluation and measurable objectives
A reasonable estimate of when goals will be reached
Frequency and duration of treatment
Specific procedures/modalities to be used, including home maintenance program

Documentation Required

Written report required for certain assessments

Some assessment services require a written report when billed; include and submit the written report with the claim or PA request as specified.

Physical performance test or measurement (97750) — with written report, PA = Yes
Assistive technology assessment — direct one‑on‑one contact, with written report, PA = Yes
Development testing with interpretation and report (G0451) — PA = Yes

Denial Risk

Triggering denial conditions: concurrent therapy and non‑therapeutic activities

Therapy is not covered when other therapy is provided concurrently using the same interventions for the same purpose, and non‑therapeutic or non‑covered purposes listed in the limitations may trigger denials.

Not covered when concurrent therapy provides the same interventions/treatment for the same purpose
Not covered for leisure activities, general exercise programs, diversion/motivation programs, long‑term therapy, developmental delay, or routine educational/training/conditioning/fitness purposes
Considered not medically necessary if the member's condition is not improving or function would improve as the member resumes normal activities

Prior Authorization

PA required for many therapy codes — obtain PA or risk denial

Services coded with CPT/HCPCS entries marked 'PA Policy = Yes' in the policy coding tables require prior authorization and may be denied if PA is not obtained prior to delivery of services.

Review coding table PA flags for each CPT/HCPCS code prior to scheduling or billing
Initial PT/OT evaluations (97161‑97164 and OT initial evaluation codes) are exempt from PA within a 6‑month period; other PA‑flagged codes are not

Includes design, fabrication, and use of orthoses; guidance in selection and use of adaptive equipment; and sensory-integrative and perceptual-motor activities.

Primary focusImprove functional performance in activities of daily living through targeted therapeutic tasks and training.