Physical & Occupational Therapy Guidelines

eviCore covers skilled PT/OT (habilitation, rehabilitation, and specified initiation of maintenance) for documented, significant functional deficits in ADLs/IADLs or complex integumentary/lymphatic conditions (e.g., wounds/burns, lymphedema, musculoskeletal, neurologic, pediatric neurodevelopmental, pelvic, swallowing/feeding, vestibular, post‑operative rehab) and excludes non‑skilled/wellness services, primarily passive/routine modalities, duplicative therapy, care for elective/recreational activities, pain‑only maintenance, and services the member’s plan specifically excludes. Key requirements: all initiation/continuation criteria must be met with objective baseline and serial standardized outcome/performance measures, a documented plan of care with specific goals and discharge plan, evidence of response (or documented new significant decline), caregiver/home‑program compliance as applicable, and adherence to plan limits and applicable CMS/MAC/LCD/state rules.