Physical Therapy Criteria

Physical therapy treatment consists of a prescribed program to relieve symptoms, improve function and prevent further disability for enrollees with acute or chronic disease or injury.  

Physical therapy is covered when all of the following criteria are met: 

1. Physical therapy is prescribed by an appropriate health care provider to improve or restore lost or impaired physical function or reduce pain resulting from illness, injury, congenital defect or surgery.
2. Physical therapy is expected to result in significant functional improvement over a clearly defined period of time.
3. An individualized written physical therapy program outlines quantifiable, attainable treatment goals.
4. Physical Therapy is covered if guidance is requested to evaluate durable medical equipment needs. 

Physical therapy services must:

• Relate directly and specifically to an active written treatment regimen established by the physician, physician assistant, or nurse practitioner after any needed consultation between the licensed physical therapist and the prescribing provider.
• Establish a plan of treatment for outpatient physical therapy that is approved by the physician, physician assistant, or nurse practitioner and complete follow-ups with the prescribing provider.

Physical 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, 1/9, 3/10, 2/11, 1/12, 1/13, 3/14, 2/15, 1/16, 1/17, 1/18, 1/19, 2/20, 10/23, 9/24

Revised:  5/21, 10/22