CurrentKaiser PermanentePolicy N/A

Outpatient and Habilitative Physical Therapy Services — Clinical Review Criteria

Clinical review criteria governing medical necessity, coverage, and exclusions for physical and occupational therapy services for Kaiser Foundation Health Plan of Washington members, including habilitative services and applicable coding guidance.

Policy Summary

PayerKaiser Permanente

PolicyOutpatient and Habilitative Physical Therapy Services — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeAdopted criteria for non‑Medicare members

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionDocument an individualized written treatment plan with quantifiable, attainable short- and long-term goals and objective outcome measures.

SourceLink

POLICY UPDATE CHANGES

Adopted criteria for Physical Therapy Services for non-Medicare members effective 02/01/2025.

Up to 6 visitsInitial eval + visits without utilization review (WA law)

~40 codesCPT/HCPCS codes listed

2025-02-01Policy effective

2024-09-03Last reviewed

Coverage and Medical Necessity Criteria

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inv-01: Rehabilitative Physical Therapy — Medical Necessity

Covered when ALL of the following are met:

Rehabilitative PT criteria: Services are necessary to improve, adapt or restore functions which have been impaired or permanently lost and/or to reduce pain as a result of illness, injury, loss of a body part, or congenital abnormality

From policy requirements

Individualized plan: The program is individualized, and there is documentation outlining quantifiable, attainable treatment goals

Potential to improve: The individual's condition has the potential to improve or is improving in response to therapy; maximum improvement is yet to be attained and anticipated improvement is attainable in a reasonable and generally predictable period of time

Objective improvement: Improvement is evidenced by successive objective measurements

Qualified provider: The services are delivered by a qualified provider of physical therapy services (appropriately trained and licensed by the state)

Skilled services required: Physical therapy is provided when the judgment, knowledge, and skills of a qualified provider are necessary to safely and effectively furnish the recognized therapy due to the complexity/sophistication of the plan of care and the individual's medical condition

inv-02: Habilitative Physical Therapy — Medical Necessity

Covered when ALL of the following are met:

Intent: Therapy is intended to keep, learn, or improve skills and functioning for daily living that have not developed or are at risk of being lost due to illness (including developmental delay), injury, loss of a body part, or congenital abnormality

Examples: child not walking or talking at expected age

Expectation of benefit: There is an expectation that therapy will improve function, assist development, or maintain an acceptable level of functioning

Evidence-based and skilled: Services are evidence-based and require the judgment, knowledge, and skills of a qualified provider due to the complexity and sophistication of the plan of care and the individual's medical condition

Risk of permanent loss: Without habilitative services, function would not be expected to develop or would be permanently lost (not merely fluctuate); if not due to loss of body part or injury, a physician experienced in the condition has confirmed the expected nondevelopment or permanent loss

inv-03: Not Medically Necessary

Behavioral-only conditions: PT services are not medically necessary when the individual's condition is strictly behavioral in nature without any associated motor involvement that impacts functional activities (e.g., ADHD, anxiety)

No potential to improve: Services are not medically necessary when the condition does not have the potential to improve or is not improving in response to therapy, or further improvement is not attainable

Spontaneous recovery expected: Services are not medically necessary when improvement or restoration of function could reasonably be expected as the individual resumes normal activities without skilled therapy (e.g., temporary post-operative weakness)

Services not requiring skilled PT: Services that do not require the skills of a qualified physical therapy provider are not medically necessary (examples: general exercise programs for fitness, general public education, massages/whirlpools for relaxation, programs primarily for athletic/recreational return)

The policy lists specific treatments and modalities that are considered experimental, investigational, unproven, or otherwise not medically necessary. Examples include infrared light therapy and other physical modalities deemed to provide minimal or no independent clinical value; devices such as vasopneumatic devices; and interventions lacking peer‑reviewed support. The policy also identifies a range of therapies considered experimental or unproven, such as elastic therapeutic taping (e.g., Kinesio™/KT tape), hydrotherapy/aquamassage, equestrian/hippotherapy, Intensive Model of Therapy (IMOT), MEDEK therapy, interactive metronome, and certain non‑invasive neurostimulation devices. In addition, programmatic interventions that are educational or vocational in nature (for example, vocational rehabilitation, back school, and work hardening programs) are specifically identified as not medically necessary under many plans.

The policy also identifies specific CPT/HCPCS codes that are associated with services considered not medically necessary, including infrared modality (97026) and codes for athletic training evaluations, work hardening, maintenance therapy, and equestrian/hippotherapy (for example, 97169–97172, 97545–97546, S8990, S9117), which should not be billed when the service meets the policy’s not‑medically‑necessary definitions.

Physical therapy services are considered not medically necessary when they lack the potential to improve or are not producing demonstrable improvement; examples include situations where further improvement is not attainable or where spontaneous recovery is expected as normal activity resumes (for example, transient weakness after brief bed rest post‑surgery).

Services that are strictly of a behavioral nature without any motor involvement that affects functional activities (for example, ADHD or anxiety) are not appropriate indications for PT and are considered not medically necessary.

Therapies that do not require the skills of a qualified physical therapist—such as general fitness or conditioning programs, general public education, relaxation massages/whirlpools for relaxation, or repetitive activities that can be self‑administered and safely practiced at home—are not medically necessary unless the policy’s specified exceptions apply. The policy also flags specific codes as not medically necessary when used to report these types of services (for example, 97026, 97169–97172, 97545–97546, S8990, S9117).

Coding and Billing Guidance

Covered/Applicable CPT CodesCPTCovered

94667	Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation
94668	Manipulation chest wall, such as cupping, percussing; and vibration to facilitate lung function; subsequent
97010	Application of a modality to 1 or more areas; hot or cold packs
97012	Traction, mechanical
97018	Paraffin bath
97022	Whirlpool
97024	Diathermy
97028	Ultraviolet
97032	Electrical stimulation (manual), each 15 minutes
97033	Iontophoresis, each 15 minutes

1–10 of 30

1/3

Considered Not Medically Necessary CodesCPT | HCPCSNot Covered

97026	Application of a modality; infrared (listed as not medically necessary)
97169	Athletic training evaluation, low complexity
97170	Athletic training evaluation, moderate complexity
97171	Athletic training evaluation, high complexity
97172	Athletic training re-evaluation
97537	Community/work reintegration
97545	Work hardening/conditioning; initial 2 hours
97546	Work hardening/conditioning; subsequent
S8990	Physical or manipulative therapy performed for maintenance rather than restoration
S9117	Back school per visit / Equestrian/hippotherapy per session

Unlisted / Not ReimbursableCPTNot Covered

97039	Unlisted modality
97799	Unlisted physical medicine/rehabilitation service or procedure

inv-09: Initial evaluation and visits without utilization review (WA law)

Scope (WA state law)RCW 48.43.016 prohibits requiring utilization management for an initial evaluation and up to six treatment visits with a contracting provider in a new episode

Included servicesInitial evaluation and management visit plus up to 6 treatment visits with a contracting provider

Verify beyond limitPrior authorization or utilization review may be required for services beyond the initial evaluation + 6 visits; verify plan-specific requirements

Applicable member typesApplies to Washington state members per statute; confirm member plan for applicability

Provider Requirements and Authorization

Prior Authorization

Prior authorization limits for initial visits — Washington law

Washington law (RCW 48.43.016) prohibits requiring utilization management for an initial evaluation and up to six treatment visits with a contracting provider in a new episode of care. Do not apply prior authorization, concurrent review, or post-service authorization requirements for those initial visits.

Applies to initial evaluation + up to six treatment visits
Do not require prior authorization, concurrent, or post-service review for those visits

Note

Benefit plan limits

Coverage for physical therapy services is subject to the member's specific benefit plan, including Short-Term Rehabilitative Therapy limits and any inpatient benefit provisions. Verify the member's plan benefits and copayment/schedule limitations before authorization or scheduling.

Check member's benefit document for plan-specific limits and copayments
Short-Term Rehabilitative Therapy benefit may impose visit or dollar limits

Documentation Required

Required documentation and treatment plan

A written, individualized treatment plan must be present and maintained in the medical record. The plan should include quantifiable, attainable short- and long-term goals, frequency and duration of treatment, target outcomes and the objective measures that will be used to assess progress.

Individualized written treatment plan with quantifiable, time-framed goals
Frequency and duration of planned visits and estimated timeframe to achieve goals
Specified objective outcome measures to assess functional improvement
Services delivered by a qualified, licensed provider per state scope of practice

Denial Risk

Documentation insufficiency

Claims and continued services may be denied or not considered medically necessary when documentation fails to objectively verify progress. Documentation must demonstrate subjective, objective and functional gains over a reasonable and generally predictable period of time; absence of such evidence creates denial risk.

Documentation must show successive objective measurements demonstrating improvement
If progress is not documented or therapy could be safely self-managed (e.g., home exercise program), services may be non‑covered
Lack of objective/functional progress over a reasonable period = denial risk

Denial Risk

Experimental or low-value modalities

Modalities or treatments that are experimental, investigational, unproven, or judged to provide minimal or no independent clinical value are not considered medically necessary. Also exclude modalities that are non‑preparatory, not supported by peer‑reviewed literature, or primarily educational/training in nature if not covered by the member's benefit.

Examples of experimental/unproven treatments: Kinesio/taping products, hydrotherapy/aquamassage, equestrian (hippotherapy), Intensive Model of Therapy (IMOT), constraint-induced movement therapy (CIMT) intensive models, MEDEK Therapy, Non‑invasive Interactive Neurostimulation (InterX), Interactive Metronome
Examples of modalities with minimal/no independent clinical value: infrared light therapy, vasopneumatic devices, modalities not preparatory to skilled procedures
Services primarily vocational, academic, or training (e.g., vocational rehab, back school, work hardening) are routinely excluded under many plans

Definitions

inv-16: Rehabilitative Physical Therapy Evaluation / Services

Rehabilitative PT definitionAssessment and therapy intended to improve, adapt, or restore function or reduce pain when individualized goals exist, improvement potential is present, objective measurements show progress, and services require a qualified, licensed provider

Key documentationIndividualized written treatment plan with quantifiable, attainable short- and long-term goals, frequency/duration, and objective outcome measures

Provider qualificationsServices must be delivered by a qualified provider of physical therapy services (appropriately trained and state-licensed)

Medical necessity signalsCondition has potential to improve or is improving; maximum improvement not yet attained; improvement evidenced by successive objective measurements

Care complexitySkilled PT judgment, knowledge, and skills are required due to complexity/sophistication of plan of care and medical condition

inv-17: Habilitative Services

Habilitative PT definitionTherapies intended to help an individual keep, learn, or improve skills and functioning that have not developed or are at risk of being lost, with expectation of meaningful development or prevention of loss

Expectation of benefitThere must be an expectation that therapy will improve function, assist development, or maintain an acceptable level of functioning

Written treatment planWritten plan must document short- and long-term goals (including estimated time to meet goals), frequency/duration, and quantitative outcome measures

Physician confirmation when requiredIf undeveloped function is not due to loss of body part or injury, a physician experienced in evaluation/management must confirm function would not develop or would be permanently lost without habilitative service

Objective verificationDocumentation must objectively verify that functional status is kept or developed

OpenPayer

Outpatient and Habilitative Physical Therapy Services — Clinical Review Criteria

Coverage and Medical Necessity Criteria

Coding and Billing Guidance

Provider Requirements and Authorization

Background and Purpose

Definitions