Site of Care: Outpatient Hospital Setting for Physical and Occupational Therapy - (0600)

Cigna covers outpatient hospital–based physical or occupational therapy only when one or more specific criteria are met—need for specialized equipment or specialized PT/OT personnel not available in freestanding facilities, no freestanding facility within a reasonable distance, or specified recent/complex conditions (e.g., amputation within 12 months, major organ transplant within 3 months, recent MI/CVA, severe neurological or high‑risk cardiac diagnoses); services for other indications are not medically necessary. Claims must include appropriate diagnosis/procedure codes and documentation proving the applicable covered criterion (e.g., equipment or personnel need, facility unavailability, operative reports/discharge summaries, or relevant procedure dates) or they will be denied.

"Physical therapy (PT) or occupational therapy (OT) services provided in an outpatient hospital setting are medically necessary for an adult or pediatric patient when ANY of the following criteria i..."