ModifiedKaiser PermanentePolicy N/A

Clinical Review Criteria — Physical Therapy Services

Defines medical necessity, coverage criteria, exclusions, and code guidance for physical therapy and related rehabilitative services for Kaiser Foundation Health Plan of Washington members.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria — Physical Therapy Services

Policy CodePolicy N/A

Change TypeAdoption of criteria for non‑Medicare members (material)

Effective Date02/01/2025

Next Review DateN/A

Key ActionVerify prior authorization requirements for requested therapy codes using the Pre-authorization Code Check and submit the last 6 months of clinical notes when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

MPC approved to adopt criteria for Physical Therapy Services for non-Medicare members with a 60-day notice and effective date 02/01/2025.

MPC approved to adopt criteria for Physical Therapy Services for non-Medicare members; requires 60-day notice, effective date 02/01/2025.

RCW 48.43.016 referencedState provision

~40 codesCodes listed

7+ requirementsHabilitative criteria

Multiple listedExperimental treatments

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02/01/2025Effective date

97039, 97537Example codes

Medical Necessity and Coverage Rules

Rehabilitative Therapy — Medical Necessity

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

Overall medical necessity: 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

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Potential for improvement: 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

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

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Objective measurement of improvement: Improvement is evidenced by successive objective measurements

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

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Skilled need: Therapy requires the judgment, knowledge, and skills of a qualified provider due to the complexity and sophistication of the plan of care and the medical condition of the individual

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Habilitative Therapy — Medical Necessity

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

Intended purpose: Therapy is intended to keep, learn, or improve skills and functioning for daily living which have not (but normally would have) developed or which are at risk of being lost as a result of illness (including developmental delay), injury, loss of a body part, or congenital abnormality

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Requires qualified provider: The physical therapy services are evidence-based and require the judgment, knowledge, and skills of a qualified provider of physical therapy services due to the complexity and sophistication of the plan of care and the medical condition of the individual

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Expectation of improvement: There is an expectation that the therapy will improve function, assist development of function, or keep an acceptable level of functioning

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Considered Not Medically Necessary

Considered Not Medically Necessary:

Not medically necessary services and codes: Services performed for maintenance rather than restoration (S8990); community/work reintegration training (97537); work hardening/conditioning (97545, 97546); back school and equestrian/hippotherapy (S9117); and unlisted modality or rehabilitation service codes (97039, 97799) when used to report treatments listed as not covered or reimbursable in this policy are considered not medically necessary.

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Services are considered not medically necessary when the individual's condition has no potential to improve or is not improving in response to therapy, when anticipated further improvement is not attainable, or when improvement would be insignificant relative to the extent and duration of therapy required. This includes transient or self-limited losses of function that would reasonably be expected to recover as the individual resumes normal activities (for example, temporary weakness after brief bed rest) and conditions strictly of a behavioral nature without motor involvement that affects functional activities.

Therapy that does not require the skills of a qualified physical therapy provider is not medically necessary. Examples include general exercise or conditioning programs intended for overall fitness, programs whose primary goal is athletic or recreational performance, massages or whirlpools provided solely for relaxation, general public education sessions, and repetitive activities that an individual can safely and effectively self-administer without skilled supervision. Documentation that fails to objectively verify subjective, objective, and functional progress over a reasonable and predictable period of time may also render services not medically necessary.

The policy lists specific CPT/HCPCS codes that are identified as not medically necessary when used as described. Examples include athletic training evaluation and re-evaluation codes 97169–97172, community/work reintegration training 97537, and work hardening/conditioning codes 97545 (initial 2 hours) and 97546 (each additional hour).

The policy also cites codes used to report maintenance or excluded services such as S8990 (maintenance therapy) and S9117 (back school/equestrian‑hippotherapy), and it identifies unlisted modality and service codes such as 97039 and 97799 when used to report treatments listed as not covered.

Operational note: the list of codes in this policy may not be exhaustive. Deleted codes and codes not in effect at the time of service may not be covered. Providers should verify current code status and coverage for the member's specific plan.

The following treatments are considered experimental, investigational, and/or unproven and therefore not medically necessary: dry hydrotherapy/aquamassage/hydromassage; elastic therapeutic taping (for example, Kinesio™/KT tape or similar products); equestrian therapy (hippotherapy); Intensive constraint‑induced movement therapy (CIMT) models 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.

Explicit examples of codes cited as considered not medically necessary include: S8990 (physical or manipulative therapy performed for maintenance rather than restoration), S9117 (back school; also listed for equestrian/hippotherapy), 97537 (community/work reintegration training, each 15 minutes), 97545 (work hardening/conditioning; initial 2 hours), 97546 (work hardening/conditioning; each additional hour), 97039 (unlisted modality), and 97799 (unlisted physical medicine/rehabilitation service or procedure).

Use of these codes to report treatments described in the policy as not covered or reimbursable will be considered not medically necessary.

CPT / HCPCS Code Guidance

Covered CPT Codes (examples)CPTCovered

94667	Manipulation chest wall; initial demonstration and/or evaluation
94668	Manipulation chest wall; subsequent
97010	Application of a modality; hot or cold packs
97012	Traction, mechanical
97014	Electrical stimulation (unattended)
97016	Vasopneumatic devices
97018	Paraffin bath
97022	Whirlpool
97024	Diathermy (eg, microwave)
97028	Ultraviolet

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Considered Not Medically Necessary / Excluded Codes (examples)mixedNot Covered

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, 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
S9117	Back school, per visit
S9117	Equestrian/hippotherapy, per session

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Considered Not Medically Necessary (examples)CPT/HCPCSNot Covered

97537	Community/work reintegration training, direct one-on-one contact, 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; equestrian/hippotherapy, per session

Unlisted modality/service codesCPTNot Covered

97039	Unlisted modality (specify type and time if constant attendance)
97799	Unlisted physical medicine/rehabilitation service or procedure

Significant developmental delay threshold

Significant developmental delay thresholdScore below the 7th percentile (or 1.5 standard deviations below the member's expected mean) on a standardized test of activities of daily living or motor skills; OR when unable to complete testing, professional determination by an OT or PT that the individual has a commensurate delay.

Alternative when testing not possibleIf the individual cannot participate in standardized testing (due to age or inability to cooperate), an occupational or physical therapist may determine delay equivalent to scoring below the 7th percentile.

Applies toAssessment of significant delay for developmental disorders when considering therapy services for individuals with developmental delays and disorders.

97537 time unit

Authorization, Documentation, and Denial Triggers

Prior Authorization

Prior authorization guidance

Verification of prior authorization requirements varies by plan. Before scheduling services, check the member's benefit plan for preauthorization requirements using the Pre-authorization Code Check. If the benefit plan requires prior authorization, obtain approval per plan procedures before providing non-emergent services.

Use Pre-authorization Code Check to verify authorization requirements by plan type.
Authorization requirements may differ for Medicare vs non‑Medicare and by commercial plan.

Prior Authorization

Prior authorization verification

Some CPT/HCPCS codes and specific service types may require prior authorization. Always verify whether the requested code(s) require authorization for the member's plan using the Pre-authorization Code Check and document the authorization number and approval dates in the medical record.

Codes frequently needing verification include unlisted modalities (e.g., 97039), certain work-related services (97537, 97545, 97546), S‑codes (e.g., S8990, S9117), and other codes noted in the policy.
If authorization is required, retain authorization details (reference number, approved dates, units, and any clinical limitations) in the chart.

Background and Rationale

Physical therapy (physiotherapy) uses exercises, hands‑on techniques, modalities, education, and goal setting to improve or restore physical function lost from injury, congenital anomaly, or chronic disease. The goal of PT is to reduce pain, improve mobility and function, and restore the ability to perform activities of daily living when there is a reasonable expectation of improvement within a generally predictable timeframe.

Coverage requires a written treatment plan established by a qualified therapist, physician, or non‑physician provider, with specific therapeutic goals, frequency and duration, objective outcome measures, and delivery by a licensed provider whose skills are necessary due to the complexity or sophistication of the plan of care.

Key Definitions and Code Descriptions

Habilitative services definition

DefinitionHabilitative services are therapy intended to keep, learn, or improve skills and functioning for daily living that have not developed or are at risk of being lost.

Plan requirementsRequires a written treatment plan documenting short- and long-term goals, frequency/duration, and quantitative outcome measures with expectation of improvement or prevention of loss.

Provider qualificationsServices must be delivered by a qualified provider (licensed physical therapist or occupational therapist) within their scope of practice.

Expectation of benefitThere must be a reasonable expectation that therapy will improve function, assist development, or prevent functional loss.

97537 — Community/work reintegration training

97537 description

Policy Updates and Effective Dates

2025-02-01policy_effective_dateLatest

Policy adoption for Physical Therapy Services for non‑Medicare members became effective following required notice.

2024-09-03MPC_approval

MPC approved adoption of criteria for Physical Therapy Services for non‑Medicare members and established a 60‑day notice requirement before implementation.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria — Physical Therapy Services

Policy CodePolicy N/A

Change TypeAdoption of criteria for non‑Medicare members (material)

Effective Date02/01/2025

Next Review DateN/A

Key ActionVerify prior authorization requirements for requested therapy codes using the Pre-authorization Code Check and submit the last 6 months of clinical notes when requesting coverage.

SourceLink

On This Page

Physician confirmation when not due to loss/injury: If the undeveloped or impaired function is not the result of a loss of body part or injury, a physician experienced in the evaluation and management of the undeveloped or impaired function has confirmed that the function would not be expected to develop or would be permanently lost without the habilitative service

Written treatment plan: There is a written treatment plan documenting short- and long-term goals (including estimated time when goals will be met), frequency and duration of treatment, and the quantitative outcome measures to be used to assess function objectively

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Documentation of functional status: Documentation objectively verifies that, at a minimum, functional status is kept or developed

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Delivered by qualified provider: Services are delivered by a qualified provider of physical therapy services

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Each 15 minutes of direct one-on-one contact by provider.

Typical usesCommunity/work reintegration training (eg, shopping, transportation, money management, avocational activities, work environment/task analysis, assistive device training).

Reporting noteCode reported in 15-minute units for direct one-on-one provider contact.

97545 initial time

97545 initial timeInitial session covers the first 2 hours of work hardening/conditioning.

Service typeWork hardening/conditioning program initial timeframe.

DocumentationReport as initial 2-hour code; additional hours handled with the appropriate add-on code.

97546 increment

97546 incrementEach additional hour of work hardening/conditioning (listed separately in addition to the primary procedure).

UseReport for each additional hour beyond the initial 2 hours coded with 97545.

Billing noteList separately in addition to the code for the primary procedure.

Note

Benefit plan dependent limits

Coverage, limits, and copayment obligations for physical therapy services depend on the member's specific benefit plan. Refer to the individual benefit plan document for details on short‑term rehabilitative therapy benefits, inpatient therapy coverage, visit limits, and member cost sharing.

Benefit plan documents determine applicable visit/episode limits and copayments.
Washington state law may afford specific protections (e.g., initial evaluation + up to six treatment visits without utilization review for contracting providers).

Documentation Required

Required documentation

Submit documentation to support medical necessity when requesting services. At minimum, include the last 6 months of clinical notes from the requesting provider and/or specialists, a written therapy plan with short‑ and long‑term goals, frequency and duration, and the objective outcome measures to be used. Ensure documentation shows measurable, successive improvement or a reasonable expectation of improvement.

Last 6 months of clinical notes from the requesting provider and/or specialist.
Written treatment plan documenting short‑ and long‑term goals, estimated timeframe, frequency and duration, and objective outcome measures.
Objective measurements demonstrating progressive improvement or justification for continued skilled services.

Documentation Required

Documentation and authorization verification

Follow professional documentation standards (APTA) and CMS guidance when preparing medical records. Always verify authorization status with the Pre-authorization Code Check prior to rendering services and include authorization details in the medical record. Documentation should objectively verify subjective, objective and functional progress over a reasonable and predictable period of time.

Adhere to APTA and CMS documentation expectations for skilled therapy.
Verify and record prior authorization details with Pre-authorization Code Check.
Charts must document clinically measurable progress or clear rationale for habilitative/maintenance services when applicable.

Denial Risk

Denial triggers for excluded or not-covered services

Services that are excluded, maintenance rather than restorative, duplicative, or otherwise not medically necessary may be denied. Examples include maintenance therapy (S8990), back school (S9117), equestrian/hippotherapy (S9117), work hardening/conditioning (97545, 97546), community/work reintegration (97537), unlisted modalities (97039), and unlisted PM&R services (97799). Use Pre-authorization Code Check to confirm coverage status and avoid billing for excluded services.

Maintenance therapy reported with S8990 is considered not medically necessary.
Work hardening/conditioning (97545, 97546) and community/work reintegration (97537) are considered not medically necessary in this policy.
Unlisted modality (97039) and unlisted physical medicine/rehabilitation service (97799) are not covered when reporting excluded treatments.

Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact by provider, each 15 minutes.

Typical activitiesIncludes shopping, transportation, money management, avocational activities, work environment/task analysis, and assistive device training.

Unit of serviceBilled in 15-minute increments for direct one-on-one provider contact.

97545 — Work hardening/conditioning; initial 2 hours

97545 descriptionWork hardening/conditioning; initial 2 hours.

Initial serviceUse 97545 to report the initial 2-hour session of a work hardening/conditioning program.

Program contextPart of structured work hardening/conditioning interventions to restore job-related physical function.

97546 — Work hardening/conditioning; each additional hour

97546 descriptionWork hardening/conditioning; each additional hour (List separately in addition to code for primary procedure).

Add-on useReported for each additional hour beyond the initial 2 hours coded with 97545 and listed separately in addition to the primary procedure.

Billing guidanceEnsure 97546 is appended as an additional-hour code when services exceed the initial 2-hour session.

S8990 — Maintenance therapy

S8990 descriptionPhysical or manipulative therapy performed for maintenance rather than restoration.

Coverage stanceListed as considered not medically necessary when services are performed for maintenance rather than restoration.

Denial triggerUse of S8990 to report maintenance therapy may be considered not medically necessary and trigger denial.

S9117 — Back school / Equestrian / hippotherapy per session

S9117 descriptionsBack school, per visit; also listed for equestrian/hippotherapy per session in the document.

Coverage stanceListed among services considered not medically necessary when used as described in the policy.

Typical reportingReport S9117 per visit or per session depending on the service provided (back school or hippotherapy).

97039 — Unlisted modality

97039 descriptionUnlisted modality (specify type and time if constant attendance).

Documentation requirementWhen billing 97039, specify the modality type and time if the service requires constant attendance.

Coverage stanceUse of 97039 to report treatments listed as not covered may be considered not medically necessary.

97799 — Unlisted physical medicine/rehabilitation service or procedure

97799 descriptionUnlisted physical medicine/rehabilitation service or procedure.

Use guidanceProvide sufficient description and documentation when reporting 97799; unlisted codes used to report excluded treatments may be not covered.

Policy noteCodes without an assigned procedure that report treatments listed as not covered may be considered not medically necessary.