Physical & Occupational Therapy Guidelines

Covered: medically necessary skilled PT/OT are authorized for specified conditions (e.g., lymphedema CDT for Stage II/III, pelvic floor/pain, vestibular disorders/BPPV, systemic autoimmune arthropathies, CRPS, neurologic impairments) when services require therapist expertise; excluded are self‑administered care, passive modalities beyond the acute phase, preventive/palliative services, routine/non‑skilled or duplicate care, and services by unqualified staff. Key requirements: providers must document at least two qualifying findings (one addressing functional limitation), meet specified objective outcome thresholds (e.g., PSFS avg ≤7/10, TUG >13.5s, Berg <45, DHI >30, ABC <67% as applicable), submit timely authorization/updated clinical notes (initial auth within ~7 days of evaluation; ongoing prior to expiration), and observe condition‑specific contraindications (e.g., lymphedema acute infection, DVT, active malignancy).

"Shoulder Bursitis"