Physical & Occupational Therapy Guidelines

Outpatient PT/OT is covered when treating a covered injury/illness that causes functional deficits limiting ADLs or return‑to‑work and is expected to produce measurable functional improvement in a reasonable timeframe (or qualifies as skilled maintenance requiring licensed therapist expertise); excluded are palliative or preventive care, group exercise, passive/unskilled modalities beyond the acute phase, standalone massage, services by non‑recognized providers (including athletic trainers), PTA‑delivered maintenance in outpatient/home settings, and therapy solely for pain control or routine non‑skilled exercise. Coverage requires a physician order (unless direct‑access state), an initial treatment plan with objective data and measurable goals, per‑session reassessments with standardized outcome measures, documentation of at least two qualifying findings (one functional), formal reevaluation at least every 30 days, and, for skilled maintenance, clear documentation that specialized therapist skill, instruction, or periodic re‑evaluation is necessary.