Cigna Medical Coverage Policy- Therapy Services Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations and Re-evaluations

Coverage Summary

Scope: This policy defines medical necessity criteria, coding guidance, and billing considerations for initial evaluations and re-evaluations performed by Physical Therapy (PT), Occupational Therapy (OT), Athletic Training (AT), and Speech-Language Pathology (SLP) clinicians under Cigna/ASH medical coverage policies. Payers: Cigna / ASH (coverage guidance applies to standard benefit plans administered by Cigna Companies; specific plan documents govern benefits when conflicts exist). Services covered: evaluation and re-evaluation services for PT, OT, AT, and SLP (with associated CPT/HCPCS codes listed in the coding sections). Coverage stance: covered_with_criteria. Policy dates: Effective 07/15/2025; Next review 07/15/2026.

Medical-Necessity Criteria

Initial Evaluation — PT / OT / AT

Initial evaluation is covered when ALL of the following are met:

ALL of the following

This is the patient’s first encounter with the practitioner or practitioner group
Patient presents with a new injury or new condition OR the same or similar complaint after discharge from previous care
Evaluation documents necessity of a course of therapy through objective findings and subjective patient/caregiver report and is completed by the therapist or physician/Non-Physician Practitioner who will provide the therapy
Choice of specific CPT evaluation code depends on documented level of complexity (low/moderate/high) using specified components

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Components for Selecting PT Evaluation Code (97161-97163)

Select code when ALL the listed components for that complexity level are documented:

97161 (low complexity)

History with no personal factors and/or comorbidities that impact plan of care
Examination using standardized tests and measures addressing 1-2 elements from body structures/functions, activity limitations, and/or participation restrictions1-2 elements
Presentation: Clinical presentation stable and/or uncomplicated
Decision-making: Clinical decision-making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome

Components for Selecting OT Evaluation Code (97165-97167)

Select code when ALL of the corresponding components are documented:

97165 (low complexity)

Occupational profile and medical/therapy history (brief review)
Assessments identify 1-3 performance deficits1-3 deficits
Decision-making: Clinical decision-making of low complexity; patient presents with no comorbidities that affect occupational performance

97166 (moderate complexity)

Occupational profile:

Components for Selecting AT Evaluation Code (97169-97171)

Select code when ALL of the corresponding components are documented:

97169 (low complexity)

History and physical activity profile with no comorbidities that affect physical activity
Examination addressing 1-2 elements from body structures, physical activity, and/or participation deficiencies1-2 elements
Decision-making: Clinical decision-making of low complexity

97170 (moderate complexity)

History:

Re-evaluation — PT / OT / AT

Re-evaluation services are medically necessary when ALL of the following are met:

ALL of the following

Not routine: Re-evaluation is not a recurring routine assessment of patient status (not routine progress notes, discharge summaries, or ongoing session assessments)
Documentation includes: evaluation of progress toward current goals; professional judgment about continued care; professional judgment about revising goals and/or treatment or terminating services
Indication: AND there is an exacerbation or significant change in patient/client status or condition
Required elements: Re-evaluation must include data collection with objective measurements, judgment whether skilled care is warranted, organization/prioritization of problem areas, identification/modification of interventions, revision of plan of care if needed, correlation to meaningful change in function, and assessment of intervention effectiveness

Re-evaluation — SLP

SLP re-evaluation is covered when ALL of the following are met:

ALL of the following

Purpose: Re-evaluation is the re-assessment after an intervention plan has been instituted to determine change in treatment needs
Clinician judgment: Decision made by clinician as professional judgment about continued care, modifying goals/treatment, or terminating services
Distinct service: Formal re-evaluation is covered only if documentation supports need for further tests and measurements beyond initial evaluation (distinct, separately identifiable service requiring SLP skill)
Not routine: Re-evaluations are not routine/recurring and continuous assessment is not a re-evaluation

Established patient re-evaluation medical necessity

Re-evaluations are medically necessary when ALL of the following are met:

ALL of the following

Not routine: Re-evaluation is not a recurring routine assessment of patient status
Documentation elements
- Progress: An evaluation of progress toward current goals
- Continued care: Making a professional judgment about continued care
- Revise/terminate:

Re-evaluation exclusion (not medically necessary)

Re-evaluation NOT considered medically necessary when:

ANY of the following

Routine assessment: Re-evaluation is a recurring routine assessment of patient status
Maximum benefit: Patient has reached maximum therapeutic benefit for services provided and no valid documented reason for re-evaluation exists

Initial evaluation purpose

Initial evaluations are appropriate to:

ALL of the following

Working diagnosis: Provide the basis for determining the working diagnosis
Occupational/social issues: Reveal occupational, social and/or psycho-social issues that may impact care
Identify comorbidities: Identify co-morbid or complicating factors
Plan of care: Establish the basis for an initial plan of care including the need for additional diagnostic testing and referral to other practitioners

E/M code selection rules

Select level of Office or Other Outpatient E/M based on ONE of:

Selection basis: The total time for E/M services performed on the date of the encounter (and documented when used as basis) OR the level of medical decision making as defined for each service

Default rules: If provider fails to indicate whether time or MDM was used and time is not clearly documented, default to medical decision-making criteria; if provider submits amended documentation documenting time in a reopen/reconsideration request, level will be re-evaluated using time guidelines

Prolonged services (99417) coding criteria

Use 99417 only when ALL of the following are met:

ALL of the following

Primary E/M by time: Primary E/M was selected using time alone as the basis (i.e., 99205 or 99215)
Time beyond minimum: At least 15 minutes of time beyond the minimum required for the highest level E/M has been exceeded (e.g., >60 minutes for 99205, >40 minutes for 99215)15 minutes beyond minimum
Unit increment: Each unit of 99417 represents an additional 15 minutes; do not report units <15 minutes15 minutes per unit

Established patient E/M / Re-evaluation administrative rule for specialties

Specialty rule (excluding Naturopathy and Podiatry):

ALL of the following

No prospective approval: Established patient E/M services or re-evaluations cannot be approved prospectively (service to be rendered in the future)
New findings required for future re-eval: If future re-evaluation is needed based on a new problem/abnormality, submission of new examination findings is required
Documentation requirement: An established patient E/M service without documentation of at least two of three required E/M elements (history, examination, level of complexity of medical decision making) cannot be approved2 of 3 elements

Coding

Physical Therapy Evaluation Codes (covered with criteria)CPTCovered

97161	Physical therapy evaluation, low complexity
97162	Physical therapy evaluation, moderate complexity
97163	Physical therapy evaluation, high complexity
97164	Physical therapy re-evaluation

Occupational Therapy Evaluation Codes (covered with criteria)CPTCovered

97165	Occupational therapy evaluation, low complexity
97166	Occupational therapy evaluation, moderate complexity
97167	Occupational therapy evaluation, high complexity
97168	Occupational therapy re-evaluation

Athletic Training Evaluation Codes (covered with criteria)CPTCovered

97169	Athletic training evaluation, low complexity
97170	Athletic training evaluation, moderate complexity
97171	Athletic training evaluation, high complexity
97172	Athletic training re-evaluation

Speech / Hearing Evaluation Codes (covered with criteria)CPTCovered

92521	Evaluation of speech fluency
92522	Evaluation of speech sound production
92523	Evaluation of speech sound production with language comprehension/expression
92524	Behavioral and qualitative analysis of voice and resonance
92610	Evaluation of oral and pharyngeal swallowing function
S9152	HCPCS code sometimes used for SLP re-evaluation (not separately priced by Medicare Part B)

Evaluation and Management Codes (informational)CPT

99202	Office/outpatient new patient E/M
99203	Office/outpatient new patient E/M
99204	Office/outpatient new patient E/M
99205	Office/outpatient new patient E/M
99211	Office/outpatient established patient E/M
99212	Office/outpatient established patient E/M
99213	Office/outpatient established patient E/M
99214	Office/outpatient established patient E/M
99215	Office/outpatient established patient E/M

Codes Not to Bill with Initial Evaluation (bundling / CCI edits)CPTNot Covered

95851-95852	Range of motion (ROM) physical performance test/measurement (included in initial evaluation)
97750	Assistive technology assessment (included in initial evaluation)
97755	Assistive technology assessment (included in initial evaluation)
97039	Unlisted physical medicine/rehab service (do not bill for re-evaluations)
97139	Unlisted therapy service (do not bill for re-evaluations)
97799	Unlisted rehab code (do not bill for re-evaluations)

Office or Other Outpatient E/M CPT codes (New Patient)CPTCovered

99202	New patient office/outpatient E/M - time 15-29 minutes; Medical decision making = Straightforward
99203	New patient office/outpatient E/M - time 30-44 minutes; Medical decision making = Low
99204	New patient office/outpatient E/M - time 45-59 minutes; Medical decision making = Moderate
99205	New patient office/outpatient E/M - time 60-74 minutes; Medical decision making = High

Office or Other Outpatient E/M CPT codes (Established Patient)CPTCovered

99211	Established patient E/M - time NA; medical decision making N/A
99212	Established patient E/M - time 10-19 minutes; Medical decision making = Straightforward
99213	Established patient E/M - time 20-29 minutes; Medical decision making = Low
99214	Established patient E/M - time 30-39 minutes; Medical decision making = Moderate
99215	Established patient E/M - time 40-54 minutes; Medical decision making = High

Prolonged service add-on codeCPTCovered

99417

Prolonged total time add-on for office/outpatient E/M (used when primary E/M selected by time and threshold exceeded by 15 minutes)

Billing constraints and provider actions: Only one initial evaluation code is billed per patient encounter/episode (evaluation codes are untimed and billable as one unit; if an evaluation spans multiple days bill one unit on the day the evaluation is completed). Re-evaluations are untimed and billed as one unit and must meet re-evaluation documentation requirements (progress toward goals, professional judgment about continued care, and objective measurement showing significant change or exacerbation). Do not bill ROM or assistive technology assessment codes (CPT 95851-95852, 97750, 97755) or unlisted therapy/re-evaluation codes (e.g., 97039, 97139, 97799) on the same day as an initial evaluation or in place of a re-evaluation because those procedures are included in evaluation codes and CCI edits prohibit separate billing. For prolonged office/outpatient E/M services, report 99417 only when time-based selection of a primary E/M (99205 or 99215) exceeds the minimum by at least 15 minutes; each unit represents 15 additional minutes and time for separately reported services is not counted toward the threshold.

Provider Actions & Billing Rules

Documentation Required

Document components for level selection

Document the history, examination elements, clinical presentation, clinical decision-making, and plan of care showing the required numbers of elements, comorbidities, and performance deficits that support the selected PT/OT/AT evaluation CPT code level. Include standardized tests/measures or outcome instruments where appropriate and complete the documentation by the therapist or clinician who will provide the therapy.

Affected codes: 97161, 97162, 97163, 97165, 97166, 97167, 97169, 97170, 97171

Billing Rule

Single initial evaluation code per episode

Only one initial evaluation code should be billed for the patient encounter/episode. Evaluation codes are untimed and billed as one unit. If the evaluation spans multiple days, bill one unit on the day the evaluation is completed. Do not bill an initial evaluation for each therapy discipline on more than one date of service unless a new, unrelated diagnosis occurs. If treatment is provided the same day, bill treatment codes separately and document the distinct treatment provided.

Background

Background and purpose: The Cigna/ASH medical coverage policy provides guidance for interpreting standard benefit plans administered by Cigna Companies and clarifies that the customer's specific benefit plan document governs when conflicts exist. The policy details the components of evaluations and re-evaluations, coding tips, and examples to support appropriate CPT code selection and medical necessity determinations for therapy evaluations and re-evaluations, and includes coding lists, documentation expectations, and billing guidance to help providers select the correct CPT codes and substantiate medical necessity.

Medicare Local Coverage Determinations (LCDs)

Type	Number	Name
LCD	L33631	OUTPATIENT Physical and Occupational Therapy Services
LCD	L33580	SPEECH-Language Pathology
LCD	L35070	SPEECH - Language Pathology (SLP) Services: Communication Disorders

Revision History

2025-07-15policy_effectiveLatest

Policy effective date; status CURRENT per brief.

2026-07-15upcoming_review

Next scheduled policy review.