Physical Therapy (PT) and Occupational Therapy (OT) Services

This policy covers physical therapy (PT) and occupational therapy (OT) services when medically necessary to restore or improve function for individuals with functional impairment from disease, trauma, congenital anomalies, or prior therapeutic intervention, including one‑to‑one aquatic therapy and standard PT/OT modalities. Illinois requires coverage for children clinically/genetically diagnosed with conditions causing low‑tone neuromuscular, neurological, or cognitive impairment, and Montana, Oklahoma, and Texas have limited direct‑access provisions allowing PT evaluation/treatment without a physician referral per state law. Coverage requires individualized, licensed‑provider delivery under a physician/qualified‑provider‑approved written plan of care with a reasonable expectation of durable, condition‑specific improvement (generally 4–6 months); maintenance/supportive, group/unlicensed, undocumented, out‑of‑benefit, or services lacking prior authorization/referral per the member’s plan/state rules are not covered.