Occupational Therapy Criteria

 Occupational therapy involves the use of purposeful activities to help people regain performance skills lost through injury or illness.  

Occupational therapy is considered medically necessary and covered when one of the following criteria is met and occupational therapy is prescribed by an appropriate health care provider to improve or restore lost or impaired function, and/or improve pain.

1. To provide task-oriented therapeutic activities and/or exercises designed to significantly improve pain, and/or significantly improve, develop or restore physical functions lost or impaired as a result of disease, injury, congenital defect, or surgery.
2. To learn or relearn daily living skills or compensatory techniques to improve the level of independence in activities of daily living
3. To evaluate durable medical equipment requirements.

The occupational therapy care plan is required to contain documentation of the medical necessity of such treatment as evidenced by:

1. Occupational therapy is provided in accordance with an ongoing written plan of care. The health care provider assists in the determination of appropriate adaptive equipment when functional disability is present and in the education needed to utilize the equipment.
2. Sufficient information is included in the plan of care to determine the medical necessity of treatment.
3. The plan of care is signed by the attending physician and licensed occupational therapist.

Occupational therapy is no longer considered medically necessary when:

• There is no measurable improvement in the condition being treated.
• No improvement or stabilization occurs, despite alterations in the treatment program.

Approved:  8/06

Reviewed:  2/07, 2/08, 3/10, 2/11, 1/12, 1/13, 3/14, 2/15, 1/16, 1/17, 1/18, 1/19, 2/20, 9/22, 9/23

Revised:  1/09, 9/21, 10/24