CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Physical Therapy

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Identifies the clinical information MassHealth needs to determine medical necessity for skilled physical therapy services provided in outpatient and home settings, including coverage and prior authorization requirements.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Physical Therapy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApril 24, 2018

Next Review DateN/A

Key ActionObtain prior authorization for physical therapy services after the 20th visit within a 12-month period and submit documentation supporting medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

After visit 20Prior authorization trigger

8Core coverage considerations

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CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Physical Therapy

Customize your policy alerts

Sign up for all Massachusetts Executive Office of Health and Human Services policy alerts

Know when Massachusetts Executive Office of Health and Human Services releases new policies or updates existing guidance.

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Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Physical Therapy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApril 24, 2018

Next Review DateN/A

Key ActionObtain prior authorization for physical therapy services after the 20th visit within a 12-month period and submit documentation supporting medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

After visit 20Prior authorization trigger

8Core coverage considerations

Noncovered circumstances

2Concurrent-therapy duplication settings

6Treatment-plan elements

Medical Necessity Coverage Criteria

Clinical coverage

Covered when all core medical-necessity elements are met.

Core skilled physical therapy coverage

Functional impairment affecting ADLs or IADLs
- Sensory or motor impairment: Problems may involve sensory processing, attention or cognition, circulation, cranial or peripheral nerve integrity, ergonomics or body mechanics, gait, locomotion or balance, integumentary integrity, joint integrity or mobility, motor function, muscle performance, neuromotor development, posture, range of motion, or reflex or sensory integrity.
- Cognitive impairment: Problems may involve orientation, concentration, comprehension, learning, organization of thought, problem-solving, or memory that affect functional capabilities.
- Respiratory impairment: Impairments may involve aerobic capacity, aerobic endurance, ventilation, or respiration.
Medical evaluation and referral: The prescribing provider has conducted and documented a medical history and physical examination identifying factors or medical conditions contributing to the functional impairments and need for skilled therapy, and has issued a written referral directed to a specific disease, injury, or congenital anomaly.
Comprehensive physical therapist evaluation: A licensed physical therapist's evaluation accompanies the referral and addresses the condition and onset or exacerbation; current and prior function; medical tests and measures; prior medical care; current medical status, comorbidities, and complicating physical, social, or cognitive factors; and objective, measurable, functional assessment tests appropriate to the condition.
Written treatment plan: A physical therapist-developed plan is specific to the disorder and includes functional goals for each identified problem, interventions and procedures with amount, frequency, and duration, measurable short- and long-term goals, member and caregiver education, a detailed home exercise or activity program with demonstrated compliance, and discharge plans.
All listed treatment-plan elements are required.
Progress documentation: Progress reports or treatment-session summaries justify the plan and services, review progress toward current goals, and provide professional judgment regarding response to treatment, continued care, goal or treatment modification, or termination. Concurrent therapy documentation must show no duplication and identify goals addressed in both settings.
Requested skilled service type: The requested service includes evaluation, therapeutic exercise, functional training, or mechanical and electrotherapeutic modalities directed toward functional improvement or prevention of worsening.
At least one listed service type must be requested.
Reasonable and necessary skilled treatment: The condition requires complexity and sophistication safely and effectively performed only by a licensed physical therapist; the treatment is specific and effective and is expected to significantly improve the condition within a reasonable and predictable period or prevent worsening; amount, frequency, and duration are professionally reasonable and supported by successive objective measurements; services are provided under a licensed prescribing provider's care with a written plan developed in consultation with a licensed physical therapist; and the setting is appropriate to the condition and activity.
All listed reasonableness and necessity elements apply.

Noncoverage

Not medically necessary when any listed noncoverage circumstance applies. These examples are not exhaustive.

Noncovered circumstances

Routine, general, or nontherapeutic services: Services are nondiagnostic, nontherapeutic, routine, repetitive, intended for general welfare, overall fitness, endurance, diversion, or general motivation, or do not require licensed physical therapist skills.
Duplicative services: Therapy replicates concurrent occupational, speech and language, other-setting, or same-setting services with similar goals, plans, modalities, or treatment content.
Temporary or self-correcting impairment: The impairment is a temporary loss or reduction expected to improve with resumption of activity, is self-correcting, or is expected to resolve through further development without treatment.
No medical condition or insufficient complexity:

Physical therapy is not medically necessary when services are nondiagnostic, nontherapeutic, routine, or repetitive; intended to maintain general welfare, promote overall fitness or endurance, provide diversion or motivation; or otherwise do not require the skills of a licensed physical therapist. Services that are primarily educational, vocational, recreational, emotional, or psychological in purpose are also excluded, as are maintenance services that do not require the specialized knowledge and judgment of a licensed physical therapist.

Services are also not medically necessary when they duplicate concurrent treatment provided by another therapy type, another provider, or another setting, including occupational therapy or speech and language therapy. Concurrent services must have sufficiently different goals, treatment plans, and therapeutic modalities to support separate treatment. Research or experimental services are not covered.

Home-based physical therapy is not medically necessary when the services are more appropriately provided in a setting other than the member's home or when the member's needs cannot be met in the home setting. The requested setting must be appropriate to the member's condition and the activities required for safe and effective treatment.

Physical therapy is not medically necessary when the requested services do not require the skills of a licensed physical therapist. This includes nondiagnostic, nontherapeutic, routine, or repetitive procedures; general exercise for fitness or endurance; services provided for diversion, general motivation, or general welfare; and other interventions that can be safely and effectively provided without the specialized knowledge and professional judgment of a licensed physical therapist.

Physical therapy is not medically necessary for an impairment that is temporary, self-correcting, or expected to resolve without treatment, including a temporary loss or reduction of function reasonably expected to improve as the member resumes activity or continues to develop. Services are also not medically necessary when the condition can be treated at a lower level of service, is not associated with a medical condition, or is not reasonable or necessary for the diagnosis or treatment of an illness or injury.

Requests may be denied when therapy duplicates concurrent services with similar goals, plans, or modalities, whether provided by another therapy type, another provider, or in another setting. The record must include objective clinical documentation supporting the need for therapy or continued therapy and a treatment plan that supports the requested services. Services are not medically necessary when the treatment plan or supporting documentation is absent or insufficient, or when maintenance of functional skills does not require specialized therapist knowledge and judgment.

Coding and Authorization Threshold

Required diagnosis codingICD-10

ICD-CM	ICD-CM code specific to the primary diagnosis for which services are requested
ICD-CM	ICD-CM code specific to the secondary medical condition

Prior Authorization Threshold

Prior authorization requirementPrior authorization is required for physical therapy services for all members after the 20th visit within a 12-month period.

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required After 20 Visits

Prior authorization is required for all members after the 20th physical therapy visit within a 12-month period. The request must include clinical documentation supporting medical necessity for the services requested.

Trigger: after visit 20 within a rolling 12-month period.

Documentation Required

Request Form and Diagnosis Documentation

Submit the applicable Request and Justification for Therapy Services Form completed in its entirety, with diagnosis and impairment information specific to the requested treatment.

Primary diagnosis name and ICD-CM code specific to the requested treatment.
Secondary diagnosis name and ICD-CM code specific to the medical condition.
Severity of signs and symptoms of functional impairments.

Physical Therapy Service Overview

Physical therapy is skilled therapy that combines diagnostic evaluation with therapeutic intervention to improve, develop, correct, rehabilitate, or prevent worsening of physical functional capabilities impaired by a specific disease, injury, or congenital disorder. It may address neuromuscular, musculoskeletal, cardiovascular, pulmonary, and integumentary dysfunctions through therapeutic exercise, manual techniques, modalities, assistive devices, and physical agents. MassHealth evaluates medical necessity based on the member's clinical information, the relative risks and benefits of treatment, and applicable requirements.

Key Definitions

Physical Therapy

DefinitionSkilled therapy services, including diagnostic evaluation and therapeutic intervention, designed to improve, develop, correct, rehabilitate, or prevent worsening of physical functional capabilities impaired or reduced by a specific disease, injury, or congenital disorder.

Rehabilitative focusTreatment emphasizes skilled rehabilitative or habilitation-focused care for dysfunctions involving the neuromuscular, musculoskeletal, cardiovascular, pulmonary, and/or integumentary systems to optimize functional levels.

Examples of skilled servicesServices may include individual rehabilitative exercises, skilled manual techniques, therapeutic modalities, assistive and adaptive devices, and physical agents and mechanical modalities.

Approved Prescribing Provider

Home health physical therapyPhysicians, podiatrists, and approved prescribers may prescribe home health physical therapy.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Physical Therapy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApril 24, 2018

Next Review DateN/A

Key ActionObtain prior authorization for physical therapy services after the 20th visit within a 12-month period and submit documentation supporting medical necessity.

SourceLink

On This Page

The service is not reasonable or necessary for an illness or injury, the disorder is not associated with a medical condition, or the condition can be treated with a lower level of service.

Inappropriate purpose or setting: Home-based services are not appropriate to the member's needs or are better provided elsewhere, or services are primarily educational, vocational, recreational, emotional, or psychological in nature.

Insufficient support or experimental treatment: There is no objective clinical documentation or treatment plan supporting therapy or continued therapy, or the services are research or experimental in nature.

Maintenance without skilled judgment: Services maintain functional skills but do not require the specialized knowledge and judgment of a licensed physical therapist for safe or effective intervention.

Documentation Required

Evaluation and Treatment Plan

Support the request with a comprehensive physical therapy evaluation and a written treatment plan that explains the member’s expected outcomes and need for continued skilled therapy.

Comprehensive physical therapy evaluation of the member’s condition.
Written treatment plan with specific, measurable goals and expected outcomes.
Member’s rehabilitation potential.
Risk factors and comorbid conditions affecting the treatment plan.
Proposed type of service, amount, frequency, and duration of treatment.
Measurable progress toward previously defined goals.

Documentation Required

Recent Progress Notes

Include recent clinical notes demonstrating the member’s current status and response to treatment.

Physical therapy progress notes from the last two weeks.
If no notes are available from the last two weeks, submit the two most recent progress notes.

Documentation Required

Concurrent Therapy and Referral Documentation

When the member receives skilled physical therapy in another setting, document why concurrent treatment is medically necessary and not duplicative.

Goals of therapy for each setting.
Treatment plans and therapeutic modalities for each setting, as applicable.
Justification that the services are sufficiently different to support continued, concurrent skilled physical therapy.

Prior Authorization

Submission Method and Submitting Provider

Clinical information must be submitted by a licensed physical therapist through an approved MassHealth submission channel.

Submit electronically through the Provider Online Service Center (POSC) whenever possible.
Alternatively, complete the MassHealth Prior Authorization Request form using the PA-1 paper form and attach all pertinent documentation.
Mail the PA-1 form and documentation to the address on the back of the form.
Include a written and signed referral or prescription from an approved prescribing provider for continued skilled physical therapy.
For POSC access questions, contact the MassHealth Customer Service Center at 1-800-841-2900.

Denial Risk

Services Do Not Require Skilled Physical Therapy

Services may be denied when they do not require the specialized skills, knowledge, and judgment of a licensed physical therapist.

Nondiagnostic, nontherapeutic, routine, repetitive, or general-welfare procedures.
General exercise, fitness, endurance, diversion, or motivational programs.
Maintenance of functional skills that can be safely and effectively performed without specialized physical therapy knowledge and judgment.

Denial Risk

Duplicative Concurrent Treatment

Services may be denied when treatment duplicates concurrent therapy across disciplines, providers, or settings.

Duplication of occupational therapy, speech and language therapy, or another type of therapy.
Duplication of services in a different setting with similar goals, plans, and therapeutic modalities.
Duplication by a different provider in the same setting with similar goals, plans, and therapeutic modalities.
Coordinate documentation across concurrent services and explain sufficiently different goals, plans, and modalities.

Denial Risk

Condition Does Not Require Skilled Therapy

Services may be denied when the condition is temporary, self-correcting, developmental, nonmedical, or can reasonably improve without skilled therapy.

Temporary loss or reduction of function expected to improve as the member resumes activities, such as deconditioning after bed rest.
Dysfunction or impairment expected to resolve through further development or without treatment.
Disorder not associated with a medical condition.
Condition or functional limitation that can be addressed by a lower level of service.
Treatment not reasonable or necessary for diagnosis or treatment of an illness or injury.

Denial Risk

Unsupported, Nonmedical, or Experimental Services

Services may be denied when they lack objective clinical support, are primarily nonmedical in purpose, or are research or experimental services.

Primarily educational, vocational, recreational, emotional, or psychological services, including services provided in a school or behavioral health setting.
No objective clinical documentation or treatment plan supporting therapy or its continuation.
Services considered research or experimental in nature.

Denial Risk

Inappropriate Home Setting

Home-based therapy may be denied when the services are more appropriately provided in another setting or the member’s needs cannot be met safely and effectively at home.

Explain why the home is the appropriate setting for the requested skilled services.
Do not request home-based services when another setting is more appropriate or the home cannot meet the member’s needs.

Outpatient or independent-therapist services

Physicians and nurse practitioners may prescribe outpatient therapy or services provided by independent therapists.