Physical & Occupational Therapy Guidelines

Covered: outpatient and home PT/OT for musculoskeletal, neurologic, vestibular, lymphedema, pelvic floor and related conditions when services are reasonable, require a licensed therapist’s skill to address functional deficits that impair ADLs/IADLs/return‑to‑work or constitute skilled maintenance; excluded are non‑skilled/self‑care, preventive or palliative‑only services, passive modalities beyond the acute phase, routine/repetitive unskilled procedures, care by unqualified staff, duplicate services, and PTAs may not provide skilled maintenance in outpatient/home settings. Key requirements: prior authorization/retrospective review must include an initial evaluation and objective documentation (typically two or more specified findings with at least one functional deficit), standardized outcome measures and numeric thresholds (e.g., ≥2 cm limb asymmetry for lymphedema, positive Dix‑Hallpike for BPPV), demonstration of measurable improvement within a generally predictable period (commonly 60–90 days) or justification for skilled maintenance, plus timely progress notes and treatment logs.