Physical & Occupational Therapy Guidelines

eviCore covers skilled PT/OT that are reasonable, necessary, and require a qualified therapist to address functional deficits affecting ADLs/IADLs or return-to-work for specified conditions (vestibular, pelvic floor, neurologic, orthopedic, pediatric, SCI, etc.), and excludes self‑administered/non‑skilled services, preventive/palliative care (except plan-specific exceptions), passive modalities beyond the acute phase, duplicate care, routine/repetitive or pain‑only therapy, and services by unqualified staff. Authorization requires an initial evaluation and ongoing documentation of objective functional measures and measurable improvement (often ≥2 qualifying findings with at least one functional or specific standardized test cutoffs), justification of frequency/duration, condition‑specific criteria, and evidence that skilled maintenance care needs therapist expertise (with Medicare/Medicaid PTA limitations).

"Authorization is based on available benefits and certificate of coverage."