PTOT Services Guidelines

Covered: Skilled PT/OT (rehabilitative, habilitative, and payer‑allowed maintenance) is authorized for documented, specific functional impairments limiting ADLs/IADLs—or for integumentary/lymphedema, musculoskeletal, neurological, pediatric neurodevelopmental, pelvic and related conditions—when the complexity requires a qualified provider and there is an expectation of a measurable favorable response leading to discharge to an independent/home program. Excluded/requirements: Routine, passive, non‑skilled, elective or experimental/investigational services are not covered; all requests must show the skills are required, include validated baseline and serial outcome measures (wound staging and weekly measures; lymphedema UE >5% or LE >10% asymmetry thresholds), a standard‑of‑care plan, patient/caregiver compliance, and documented progress to authorize or continue care.

"Initiation of skilled rehabilitation/habilitation care when ALL initiation criteria are met: (1) services meet the definition of 'Medically Necessary'; (2) the skills of a qualified provider are re..."