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CurrentKaiser PermanentePolicy N/A

Outpatient Occupational and Physical Therapy Services — Clinical Review Criteria

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Clinical review criteria governing medical necessity, coverage, and coding for outpatient occupational and physical therapy (including habilitative services) for Kaiser Foundation Health Plan of Washington members; affects providers requesting therapy services and internal utilization management staff.

Policy Summary

PayerKaiser Permanente

PolicyOutpatient Occupational and Physical Therapy Services — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeAdoption of OT criteria for non‑Medicare members

Effective DateFeb 1, 2025

Last ReviewSep 3, 2024

Next Review DateSep 3, 2024

Key ActionVerify pre-authorization requirements for specific codes by plan using the Pre-authorization Code Check and submit the last 6 months of clinical notes to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Criteria for Occupational Therapy Services for non-Medicare members were adopted.

manyApplicable procedure codes included in policy

listedNamed NMN treatments and programs

yesHabilitative OT criteria present

WA lawRCW 48.430.016 mention

Coverage and Medical Necessity Criteria

Habilitative Occupational Therapy

Habilitative services are considered medically necessary when ALL of the following are met

Habilitative OT Criteria: The therapy is intended to keep, learn, or improve skills and functioning for daily living that have not developed (but normally would have) or are at risk of being lost due to illness (including developmental delay), injury, loss of a body part, or congenital abnormality (examples: a child not walking or talking at expected age); the services are evidence-based and require the judgment, knowledge, and skills of a qualified occupational therapy provider due to complexity of the plan of care; there is an expectation the therapy will improve function, assist development of function, or maintain an acceptable level of functioning; without the habilitative service the individual would either not be expected to develop the function or would be expected to permanently lose the function (for non–loss-of-body-part causes, a physician experienced in evaluation/management must confirm that the function would not develop or would be permanently lost); documentation objectively verifies that functional status is kept or developed; a written treatment plan documents short- and long-term goals (including estimated timing), frequency and duration of treatment, and quantitative outcome measures to assess function; and services are delivered by a qualified provider of occupational therapy services.

Includes consideration for developmental delay and documentation requirements

Kaiser Permanente considers the following services not medically necessary for outpatient occupational and physical therapy when documentation or the clinical situation demonstrates they are non-skilled, duplicative, or unlikely to produce improvement. Examples include: general exercise programs intended for overall fitness or conditioning; activities provided primarily for general welfare, athletic or recreational enhancement, or public education; massages and whirlpools provided for relaxation; repetitive activities that can be self-administered safely (when a home exercise program is adequate); services requiring only routine supervision rather than skilled therapist intervention; and modalities deemed to provide minimal or no independent clinical value (for example, infrared light therapy).

Policy Summary

PayerKaiser Permanente

PolicyOutpatient Occupational and Physical Therapy Services — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeAdoption of OT criteria for non‑Medicare members

Effective DateFeb 1, 2025

Last ReviewSep 3, 2024

Next Review DateSep 3, 2024

Key ActionVerify pre-authorization requirements for specific codes by plan using the Pre-authorization Code Check and submit the last 6 months of clinical notes to support medical necessity.

SourceLink

On This Page

The following treatments and programs are considered experimental, investigational, or unproven and are therefore not covered: elastic therapeutic taping (e.g., Kinesio/TKTAPE/Spidertech), hydrotherapy/aquamassage/hydromassage, equestrian therapy (hippotherapy), Intensive Model of Therapy (IMOT) programs (including intensive CIMT), MEDEK Therapy, The Interactive Metronome Program, and non‑invasive Interactive Neurostimulation (e.g., InterX).

Specific CPT/HCPCS codes are listed as not medically necessary when used to report these or other excluded services, including but not limited to: 97026 (infrared), 97169–97172 (certain high‑complexity/athletic training codes), 97537, 97545–97546 (work hardening/conditioning), S8990 (maintenance therapy), S9117 (back school/hippotherapy), and unlisted modality/service codes such as 97039 and 97799 when used to report treatments listed as not covered.

Procedure and Billing Codes

Covered CPT Codes (examples listed)CPTCovered

97010	Application of a modality to 1 or more areas; hot or cold packs.
97012	Application of a modality to 1 or more areas; traction, mechanical.
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended).
97018	Application of a modality to 1 or more areas; paraffin bath.
97022	Application of a modality to 1 or more areas; whirlpool.
97024	Application of a modality to 1 or more areas; diathermy.
97032	Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes.
97033	Application of a modality to 1 or more areas; iontophoresis, each 15 minutes.
97034	Application of a modality to 1 or more areas; contrast baths, each 15 minutes.
97035	Application of a modality to 1 or more areas; ultrasound, each 15 minutes.

1–10 of 24

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Not Medically Necessary / Excluded CodesmixedNot Covered

97026	Application of a modality to 1 or more areas; infrared (listed as not medically necessary).
97169	Code listed under not medically necessary.
97170	Code listed under not medically necessary.
97171	Athletic training evaluation, high complexity (listed under not medically necessary).
97172	Related athletic training evaluation code (listed under not medically necessary).
97537	Code listed under not medically necessary.
97545	Work hardening/conditioning; initial 2 hours (listed under not medically necessary).
97546	Work hardening continuation code (listed under not medically necessary).
S8990	Physical or manipulative therapy performed for maintenance rather than restoration (NMN).
S9117	Back school or equestrian/hippotherapy per visit (NMN).

1–10 of 12

1/2

inv-07: Standardized test percentile threshold for developmental delay

Standardized test thresholdBelow the 2nd percentile for the lower of chronological age or developmental level (equivalent to 1.5 standard deviations below the expected mean)

Alternate determinationIf the individual cannot participate in standardized testing, a qualified OT or PT may determine delay in ADLs or motor skills commensurate with criteria

Applies toAssessment of activities of daily living or motor skills for individuals of any age when developmental delay is suspected

Provider Responsibilities and Documentation

Prior Authorization

Pre-authorization: verify per plan

Verify plan-specific pre-authorization requirements before providing outpatient occupational or physical therapy services; use the Pre-authorization Code Check for the listed CPT/HCPCS codes to determine whether an authorization is required for the member's plan.

Pre-authorization requirements vary by plan and by code.
Codes referenced in the policy include (examples): 97150, 97166, 97167, 97168, 97530, 97535, 97755, 97760, 97761, 97763, 97010, 97012, 97014, 97018, 97022, 97024, 97032, 97033, 97034, 97035, 97110, 97112, 97113, 97116, 97169, 97170, 97171, 97172, 97537, 97545, 97546, S8990, S9117, 97026, 97039, 97799

Note

Confirm medical necessity and plan of care before providing services

Confirm that services meet the policy's medical necessity criteria (e.g., demonstrable impairment, expectation of improvement or maintenance requiring skilled OT, and a written, measurable plan of care) prior to authorization and delivery.

Ensure the individual demonstrates impairment in ADLs/IADLs or usual daily activities and that skilled OT judgment is necessary.
Document expectation that improvement is attainable in a reasonable, generally predictable period and measurable with successive objective measurements.
For habilitative OT, document that services are intended to develop or preserve skills not yet developed or at risk of being lost and include a written treatment plan with short- and long-term goals.

Documentation Required

Required supporting documentation when requesting services

When requesting authorization or coverage review, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

Include documentation that objectively verifies baseline functional status, progress, and the individualized treatment plan with measurable goals and frequency/duration.
For habilitative services, include documentation confirming the function would not develop or would be permanently lost without therapy when applicable.

Denial Risk

Denial triggers for non-skilled or duplicative services

Services documented as non-skilled, duplicative, or likely to improve without skilled therapy are considered not medically necessary and are subject to denial.

Examples include general exercise programs for fitness, activities the member can safely self-administer, services requiring only routine supervision, massages/whirlpools for relaxation, and modalities deemed to provide minimal or no clinical value independently (e.g., infrared).
Denial risk increases when documentation fails to objectively verify functional progress over a reasonable and predictable period.

Clinical Background

Occupational and physical therapy are episodic, skilled health services intended to restore, improve, or maintain function and support performance of activities of daily living. Indications include musculoskeletal, neuromuscular, neurocognitive, cardiopulmonary/vascular, lymphedema, and skin pathology (including burns and scars) where there is an expectation of improvement or where maintenance requires skilled intervention.

Covered services must be directed by licensed therapists, delivered using an individualized plan of care with quantifiable, attainable goals and objective measurements of progress, and require skilled therapist judgment because of the complexity of the condition or treatment. Services that are transient, expected to improve without skilled care, duplicative of other authorized therapy, or primarily educational/ vocational in nature are considered not medically necessary and subject to denial.

Key Definitions

inv-13: Definition — Occupational therapy

DefinitionOccupational therapy is a health profession that helps people of all ages improve ability to perform daily tasks (occupations) using task-oriented therapeutic activities, exercises, adaptive equipment, and strategies to develop, recover, or maintain skills for daily living and working.

Primary goalsRelearn daily activities, restore physical functions, develop compensatory techniques, improve independence in activities of daily living

Service characteristicsProvides task-oriented therapeutic activities and exercises designed to significantly improve, develop, or restore function; delivered by licensed occupational therapists

inv-14: Definition — Physical therapy

DefinitionPhysical therapy is a dynamic profession that diagnoses and manages movement dysfunction and enhances physical and functional abilities to restore and promote optimal physical function.

Primary focusRestoration and promotion of physical function, management of movement dysfunction, and enhancement of functional abilities

Service characteristicsDelivered by qualified physical therapists using evidence-based interventions for musculoskeletal, neuromuscular, neurocognitive, vascular/lymphedema, and skin pathology or dysfunction