Occupational Therapy - (CPG155)

Occupational therapy evaluations, rehabilitative/habilitative OT, a wide range of skilled interventions and modalities (e.g., therapeutic exercise, ADL/IADL training, neuromuscular re‑education, orthotic/prosthetic training, aquatic/whirlpool/fluidotherapy, electrical stimulation, ultrasound) are covered when medically necessary, while non‑skilled, duplicative, educational/vocational/school services and experimental/unproven treatments (e.g., infrared, vasopneumatic devices) and services without potential to improve are excluded. Key requirements: medical necessity must be documented by functional impairment in ADLs/IADLs with potential to improve, individualized quantifiable goals, skilled care by qualified providers, objective evidence of progress and detailed initial/daily/progress/re‑evaluation/discharge documentation, and outpatient visits are limited to four timed units (one hour) per provider per day (coverage may vary by plan).

"An occupational therapy evaluation is considered medically necessary for the assessment of a physical and/or functional impairment as demonstrated by the inability to perform basic activities of da..."