Outpatient Physical and Occupational Therapy Services

Outpatient physical and occupational therapy is covered when therapy is individualized, medically necessary, and requires the unique skills of a qualified therapist to improve, maintain, or prevent deterioration of function, with a certified plan of care. Specific modalities and procedures are covered only for defined indications (e.g., traction for radiculopathy, vasopneumatic devices for edema/lymphedema, ultrasound for limited joint motion), while services that do not require therapist skills, packaged programs, certain modalities (e.g., dry hydrotherapy, microwave), and treatments lacking evidence are excluded. Documentation must meet Medicare minimums, certify medical necessity and skilled need, and justify frequency, modality use, and continued treatments beyond typical education or expected durations.

"Rehabilitative outpatient PT/OT is covered when the condition has potential to improve or is improving, maximum improvement is not yet attained, and anticipated improvement is attainable within a r..."