Physical & Occupational Therapy Guidelines

Therapy is covered when a functional deficit from illness/injury/congenital disorder requires therapist skill, is evidence‑based, sufficiently complex, and expected to yield significant improvement; excluded are care that is independent/home‑managed, routine/repetitive/non‑skilled, solely recreational/sports or pain‑only, duplicate, or shows no objective improvement, and several specific modalities lack sufficient evidence. Key requirements include submission of baseline functional assessments and objective outcome measures and documentation of response (or clinical justification for skilled maintenance/continuation); lymphedema care additionally requires a confirmed lymphedema diagnosis with asymmetry >2 cm or >200 mL, prior conservative measures, clinical staging, and adherence to authorization timeframes (generally 7 days).

"Physical and Occupational Therapy services are required to address a functional deficit in the individual's daily activities resulting from a physical impairment due to illness, disease, injury, or..."