Physical & Occupational Therapy Guidelines

Covered: Outpatient PT/OT is covered when provided by a qualified/licensed therapist to treat a covered injury/illness or to establish/educate/re-evaluate a skilled maintenance program and when it addresses functional deficits with measurable, diagnosis‑related goals (examples: BPPV repositioning, pelvic pain, RA, stroke/ABI, CRPS, impaired mobility); excluded are services by non‑recognized providers (athletic trainers, aides), non‑skilled or maintenance‑only care that does not require therapist skill, group therapy, passive modalities beyond the acute phase, standalone massage, duplicate therapies, and preventive/palliative‑only care. Key requirements: physician order (except in direct‑access states), an initial treatment plan with objective measures and measurable goals and a home program, reassessments at each session and formal reassessment at least every 30 days, documentation of objective improvement or condition‑specific findings (generally ≥2 findings with ≥1 functional) to justify continued treatment, and procedure‑specific documentation (e.g., positional testing for BPPV).