Physical & Occupational Therapy Guidelines

eviCore covers skilled physical and occupational therapy (rehab, habilitation, or maintenance) for wound/integumentary, lymphedema, musculoskeletal, neurological, pediatric neurodevelopmental, pelvic, swallowing/feeding, and vestibular conditions when a documented, quantified deficit significantly impairs ADLs/IADLs and requires the skills of a qualified provider, and excludes non‑skilled, routine/passive, duplicative, elective/recreational, pain‑only, or caregiver‑availability‑based services. Coverage requires current clinical documentation with baseline and serial standardized outcome measures, an evidence‑based, time‑limited plan of care with measurable goals and home program, expectation of patient/caregiver compliance and demonstrable response (or new significant decline) to justify initiation, maintenance or continuation; one isolated abnormal measure is generally insufficient and CMS/MAC/LCD/NCD policies take precedence for Medicare.

"Initiation of an episode of physical and occupational therapy services for skilled habilitation/rehabilitation will be considered medically necessary when ALL of the following criteria have been me..."