PTOT Services Guidelines

Covered: Skilled PT/OT (habilitation/rehab/maintenance) is medically necessary for integumentary, lymphatic, musculoskeletal, neurologic, pediatric neurodevelopmental, pelvic, swallowing and vestibular conditions only when it treats documented, quantifiable functional impairments or specific wound/lymphedema problems that require the skills of a qualified provider, follows a reasonable evidence‑based plan with an expectation of measurable improvement, and is not experimental. Key requirements/exclusions: Prior authorization must include standardized baseline and serial outcome measures showing new/changed deficits and ongoing response (or significant decline) with expectations for progress (e.g., wound healing over ~30 days; lymphedema asymmetry >5% UE or >10% LE); services that are passive, routine, duplicative, primarily elective/pain‑only, or experimental/investigational are excluded.

"Initiation of skilled rehabilitation/habilitation care when ALL of the following are met: (1) Meets the definition of 'Medically Necessary'; (2) The skills of a qualified provider are required to a..."