Kaiser Permanente Physical Therapy Coverage Update

Coverage Criteria — Medical Necessity and Exclusions

inv-01: Rehabilitative therapy — medical necessity — rehabilitative PT evaluation and continued services are medically necessary when ALL of the following are met

Rehabilitative Physical Therapy evaluation and continued services are considered medically necessary when ALL of the following are met:

Rehabilitative PT medical necessity: 1) The individual's condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained, and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time; 2) The program is individualized with documentation outlining quantifiable, attainable treatment goals; 3) Improvement is evidenced by successive objective measurements; 4) Services are delivered by a qualified provider of physical therapy services appropriately trained and licensed by the state; 5) Physical therapy is necessary because the judgment, knowledge, and skills of a qualified provider are required to safely and effectively furnish a recognized therapy due to the complexity and sophistication of the plan of care and the individual's medical condition, with the goal of improvement of an impairment or functional limitation.

From Kaiser Permanente rehabilitative PT criteria.

inv-02: Habilitative therapy — medical necessity — habilitative PT services are medically necessary when ALL of the following are met

Habilitative PT services are medically necessary when ALL of the following are met:

Habilitative PT criteria: 1) 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; 2) Services are evidence-based and require the judgment, knowledge, and skills of a qualified provider of physical therapy due to the complexity and sophistication of the plan of care and the individual's medical condition; 3) There is an expectation that the therapy will improve function, assist development of function, or maintain an acceptable level of functioning; 4) Without the habilitative service the individual would not be expected to develop the function or would be expected to permanently lose the function (when not due to loss of a body part or injury, a physician experienced in the condition has confirmed this); 5) A written treatment plan documents short- and long-term goals (including estimated timeframes), frequency and duration of treatment, and quantitative outcome measures to assess function objectively; 6) Documentation objectively verifies that functional status is kept or developed; 7) Services are delivered by a qualified provider of physical therapy services.

Includes Washington statutory note about initial evaluation and up to six visits exempt from utilization management as applicable.

inv-03: Not medically necessary / Exclusions — services considered not medically necessary or excluded when any of the following apply

Services considered not medically necessary or excluded when any of the following apply:

Not medically necessary conditions: - The individual's condition does not have the potential to improve or is not improving in response to therapy, or further improvement is not attainable; - Condition is strictly behavioral without associated motor involvement impacting function (e.g., ADHD, anxiety); - Improvement or restoration of function is reasonably expected with gradual resumption of normal activities without skilled therapy (e.g., transient/reversible loss, temporary weakness after brief bed rest); - Services that do not require the skills of a qualified PT provider (examples include general exercises for fitness, programs primarily for athletic/recreational enhancement, massages/whirlpools for relaxation, general public education/instruction); - Repetitive activities an individual can safely self-administer without skilled supervision; - Home exercise program is sufficient except when exceptions apply (poor technique requiring cueing/feedback, lack of support at home, cognitive impairment preventing independent completion); - Documentation fails to objectively verify subjective, objective and functional progress over a reasonable and predictable period; - Physical modalities that are not preparatory to other skilled treatment or provide minimal/no independent clinical value (e.g., infrared light therapy, vasopneumatic devices); - Treatments not supported in peer-reviewed literature; - Nonmedical/educational/work-related programs excluded under many plans (e.g., back school, vocational rehabilitation, work hardening, education/achievement testing, services duplicated from school setting); - Executive functioning services (addressing cognitive/learning deficits) considered not medically necessary; - Duplicative or redundant services expected to achieve the same therapeutic goal (e.g., multiple modalities with overlapping physiologic effects); - When multiple therapy disciplines are involved, services must be distinct, nonduplicative, and separately documented (different evaluations, treatment plans, and goals).

Combined exclusions and not medically necessary list from policy.

inv-04: Evaluation and Re-evaluation Criteria — coverage defined by meeting components for complexity level and documentation

Physical therapy evaluation and re-evaluation coverage is defined by meeting the components for complexity level and documentation:

Low complexity PT evaluation covered when ALL of the following are met: History with no personal factors and/or comorbidities that impact the plan of care; examination using standardized tests and measures addressing 1–2 elements from body structures/functions, activity limitations, and/or participation restrictions; stable and/or uncomplicated clinical presentation; clinical decision making of low complexity using standardized patient assessment instruments and/or measurable assessment of functional outcome; typically 20 minutes face-to-face.20 minutes

Corresponds to CPT 97161

Moderate complexity PT evaluation covered when ALL of the following are met: History with 1–2 personal factors and/or comorbidities that impact the plan of care; examination using standardized tests and measures addressing a total of 3 or more elements from body structures/functions, activity limitations, and/or participation restrictions; evolving clinical presentation with changing characteristics; clinical decision making of moderate complexity using standardized patient assessment instruments and/or measurable assessment of functional outcome; typically 30 minutes face-to-face.30 minutes

The policy identifies a set of therapies that are either explicitly excluded or considered to have insufficient evidence to support coverage. Treatments listed as insufficient evidence include dry hydrotherapy / aquamassage / hydromassage, elastic therapeutic tape (e.g., Kinesio™/KT TAPE™), equestrian therapy / hippotherapy, intensive models of constraint‑induced movement therapy (CIMT) and Intensive Model of Therapy (IMOT) programs, MEDEK Therapy, Non‑invasive Interactive Neurostimulation (e.g., InterX®), spinal manipulation for non‑musculoskeletal conditions, and the Interactive Metronome Program.

The policy also notes modalities and procedures considered to have minimal or no independent clinical value when not preparatory to skilled care, for example infrared light therapy and vasopneumatic devices. Additionally, nonmedical, educational, or work‑focused programs are excluded, including back school, vocational rehabilitation, work hardening, and educational testing or services duplicated from the school setting. Executive functioning therapies that address cognitive/learning skills rather than motor deficits are also considered not medically necessary.

Several CPT/HCPCS codes are designated as Considered Not Medically Necessary and therefore not covered when billed for the services described. Examples called out in the policy include 97039 (unlisted modality) and 97799 (unlisted physical medicine/rehabilitation service).

Other specific codes listed as not medically necessary include S8990 (physical or manipulative therapy performed for maintenance rather than restoration) and S9117 (back school; also used for equestrian/hippotherapy where applicable), as well as modality code 97026 (infrared) and certain athletic training and community/work reintegration codes (see code list).

The policy advises providers to verify authorization requirements for a specific code and plan type using the Pre‑authorization Code Check before billing, as code coverage and preauthorization rules may vary by benefit plan.

Physical therapy services are not medically necessary when the condition has no potential to improve or is not improving with therapy, or when further meaningful improvement is not attainable within a reasonable timeframe. The policy gives examples such as transient, spontaneously resolving deficits or temporary weakness expected to resolve with gradual resumption of normal activities.

Services are also not medically necessary when the condition is purely behavioral without associated motor involvement (e.g., ADHD, anxiety) or when improvement is reasonably expected with nonspecific activity resumption rather than skilled therapeutic intervention. Interventions that do not require the skills of a qualified physical therapist — for example, general exercise programs for fitness, massages/whirlpools for relaxation, routine repetitive activities a patient can self‑administer, or services where a home exercise program is sufficient — are excluded unless specific exceptions are documented.

Finally, documentation that fails to objectively verify subjective, objective, and functional progress over a reasonable and predictable period may render continued therapy not medically necessary.

The policy explicitly lists multiple CPT/HCPCS codes as Considered Not Medically Necessary. Examples included in the code table and supporting text are 97026 (infrared modality), the athletic training codes 97169–97172, community/work reintegration code 97537, work hardening/conditioning codes 97545–97546, maintenance therapy S8990, back school/equestrian therapy S9117, and the unlisted codes 97039 and 97799.

Use of these codes may trigger denial of coverage when billed, and providers should ensure services billed under these codes meet medical necessity criteria or select an appropriate covered code supported by documentation.

CPT / HCPCS Codes and Evaluation Parameters

HCPCS/CPT codes - modalities (part 1)mixedCovered

94667	Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial
94668	Manipulation chest wall; initial demonstration and/or evaluation; subsequent
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)
97016	Application of a modality to 1 or more areas; vasopneumatic devices
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 (eg, microwave)
97028	Application of a modality to 1 or more areas; ultraviolet

1–10 of 11

1/2

HCPCS/CPT codes - modalities, therapeutic procedures, evaluations (part 2)mixedCovered

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; Hubbard tank
97036	Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97110	Therapeutic exercises to develop strength and endurance, range of motion and flexibility
97112	Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception
97113	Aquatic therapy with therapeutic exercises
97116	Gait training (includes stair climbing)
97124	Massage, including effleurage, petrissage and/or tapotement
97140	Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

1–10 of 13

1/2

Covered CPT Codes (procedures and evaluations)CPTCovered

97110	Therapeutic procedure, 1 or more areas, each 15 minutes (therapeutic exercises)
97112	Therapeutic procedure, balance, coordination, kinesthetic sense, posture, proprioception, each 15 minutes
97113	Aquatic therapy with therapeutic exercises, each 15 minutes
97116	Gait training (includes stair climbing), each 15 minutes
97124	Massage, including effleurage, petrissage, and/or tapotement, each 15 minutes
97140	Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), each 15 minutes
97150	Therapeutic procedure(s), group (2 or more individuals)
97161	Physical therapy evaluation: low complexity
97162	Physical therapy evaluation: moderate complexity
97163	Physical therapy evaluation: high complexity

1–10 of 17

1/2

Considered Not Medically Necessary CodesmixedNot Covered

97026	Application of a modality to 1 or more areas; infrared
97169	Athletic training evaluation, low complexity
97170	Athletic training evaluation, moderate complexity
97171	Athletic training evaluation, high complexity
97172	Re-evaluation of athletic training established plan of care
97537	Community/work reintegration training, direct one-on-one, each 15 minutes
97545	Work hardening/conditioning; initial 2 hours
97546	Work hardening/conditioning; each additional hour
S8990	Physical or manipulative therapy performed for maintenance rather than restoration
S9117	Back school, per visit

1–10 of 12

1/2

Significant developmental delay — scoring thresholds

DefinitionScores below the 7th percentile or 1.5 standard deviations below the individual's expected mean on a standardized test of activities of daily living or motor skills.

Alternate assessment for untestable individualsIf an individual cannot participate in standardized testing, a designated occupational or physical therapist may determine delay in activities of daily living or motor skills commensurate with scoring below the 7th percentile.

ApplicabilityUsed when considering services for individuals with developmental delays and disorders to document significant delay warranting habilitative or rehabilitative services.

Evaluation face-to-face time by complexity

Low complexity (typical face-to-face)

Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior authorization may be required; WA law exempts initial visits

Coverage for outpatient and home physical therapy may be subject to the member's benefit plan terms and may require authorization under the Short‑Term Rehabilitative Therapy benefit; Washington law (RCW 48.43.016) exempts an initial evaluation and up to six treatment visits with a contracting provider in a new episode of care from utilization management requirements.

Verify member's Evidence of Coverage for specific benefit limits and copayments.
Washington statutory exception: initial evaluation + up to 6 treatment visits exempt from prior authorization for contracting providers in a new episode.

Prior Authorization

Check pre-authorization by plan using Code Check

Before billing or scheduling services, verify whether a specific CPT/HCPCS code requires pre-authorization for the member's plan using the Pre-authorization Code Check; the Medical Policy Committee adopted these criteria for non‑Medicare members effective 02/01/2025.

Use the Pre-authorization Code Check to determine plan-specific authorization requirements.

Background and Scope

Physical therapy (physiotherapy) is a combination of therapeutic approaches — including targeted exercises, manual techniques, physical modalities, patient education, and individualized, goal‑directed treatment plans — intended to improve, restore, or prevent loss of physical function due to injury, congenital conditions, disease, or chronic impairment.

Therapy must be part of a written plan of care established by a qualified provider and is considered medically necessary when it is expected to produce significant improvement within a reasonable timeframe; services that do not require the skills of a physical therapist or that are educational/nonmedical in nature are not eligible for coverage under the rehabilitative benefit.

Key Definitions

Physical therapy — definition

DefinitionPhysical therapy (physiotherapy) is a combination of treatments using exercises, hands-on techniques, physical stimuli, massage, education, goal setting, and record keeping to improve, develop, or correct physical functions impaired or lost due to injury, congenital anomaly, or chronic medical condition.

Plan requirementCovered when part of a written treatment plan established by a qualified physical therapist, physician, or NPP that addresses specific therapeutic goals and includes type, frequency, and duration of procedures and modalities.

Clinical purposeIntended to improve, develop, restore, or prevent worsening of physical function; requires skilled providers diagnosing and managing movement dysfunction and enhancing functional abilities.

Habilitative PT — definition

DefinitionHabilitative physical therapy is therapy intended to keep, learn, or improve skills and functioning that have not yet developed or are at risk of being lost due to illness, injury, congenital abnormality, or developmental delay; services must be evidence-based and require the judgment and skills of a qualified provider.

Policy Revision History

2025-02-01Operational effective dateLatest

Policy criteria for Physical Therapy Services for non–Medicare members became effective following MPC approval and required 60-day notice.

2024-09-03MPC approval

Medical Policy Committee approved adoption of criteria for Physical Therapy Services for non–Medicare members (MPC approval recorded).

2024-11-05MPC review

Clinical Review Criteria — Physical Therapy Services

Sign up for all Kaiser Permanente policy alerts