Aetna · Clinical coverage policy

Aetna Physical Therapy coverage criteria

Aetna covers physical therapy as medically necessary when a licensed practitioner expects significant functional improvement within about a month (or needs to establish a self-managed maintenance program), the care is skilled, follows a written plan of care, and treats a specific illness/injury; coverage stops once therapeutic goals are met or a home exercise program could sustain gains. Many methods/devices are experimental/investigational or not covered (e.g., Kinesio/McConnell taping, blood flow restriction therapy, MEDEK, virtual reality gait training), and IADL, sports/avocational rehab, non-skilled, and maintenance care are excluded; HMO plans typically cap PT at a 60-day course per condition. The bulletin is silent on whether precertification/prior authorization is required.

Policy CPB 0325 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0325

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0325 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Physical Therapy (CPT 97010), and what gets it denied?

Path
Aetna covers physical therapy as medically necessary when a licensed practitioner expects significant functional improvement within about a month (or needs to establish a self-managed maintenance program), the care is skilled, follows a written plan of care, and treats a specific illness/injury; coverage stops once therapeutic goals are met or a home exercise program could sustain gains. Many methods/devices are experimental/investigational or not covered (e.g., Kinesio/McConnell taping, blood flow restriction therapy, MEDEK, virtual reality gait training), and IADL, sports/avocational rehab, non-skilled, and maintenance care are excluded; HMO plans typically cap PT at a 60-day course per condition. The bulletin is silent on whether precertification/prior authorization is required. Coverage criteria include: Physical therapy (PT) is considered medically necessary when ALL of the following criteria are met (criteria 1-5 below).; Functional improvement / maintenance-program criterion (ONE of): the member's licensed health care practitioner has determined that the member's condition can improve significantly based on physical measures (e.g., active range of motion (AROM), strength, function, or subjective report of pain level) within one month of the date that therapy begins; OR the proposed therapy services are necessary for establishment of a safe and effective maintenance program that the member will perform WITHOUT ongoing skilled therapy services. These services must be proposed for treatment of a specific illness or injury.; Expectation of significant improvement: PT services are intended to cover only episodes of therapy for situations where there must be a reasonable expectation that the member's condition will improve significantly in a reasonable and generally predictable period of time.; Provider qualification: PT services must be performed by a duly licensed and certified (if applicable) PT provider, and all services must be within the applicable scope of practice for the provider in their licensed jurisdiction where services are provided.; Complexity and supervision: services must be of the complexity and nature requiring performance by a licensed professional therapist, OR provided under supervision by a licensed ancillary person as permitted under state laws. Services may be provided personally by physicians and performed by personnel under their direct supervision as permitted under state law; HOWEVER, because physicians are not licensed as physical therapists, they may NOT directly supervise physical therapy assistants.; Written plan of care: PT must be provided in accordance with an ongoing, written plan of care, of sufficient detail and including appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment.; Covered conditions: PT may be indicated for treatment of muscle weakness, limitations in range of motion, neuromuscular conditions, musculoskeletal conditions, lymphedema, and for selected training of patients in specific techniques and exercises for their own continued use at home. Generally covered for members with eligible conditions requiring the skills of a physical therapist, including impairments in body functions/structures, activity limitations, participation restrictions, need for management plan and plan of care, performance enhancement, transitions to different roles or settings, and risk factors for developing impairments.; Home-based physical therapy is considered medically necessary in selected cases based upon the member's needs - i.e., to address the member's functional performance and functional needs in the home environment, or as part of the transition from skilled therapy to a maintenance program.; Augmented soft tissue mobilization (use of hand-held tools for myofascial release; e.g., the Dynatronics ThermoStim probe) is considered medically necessary and covered as a standard myofascial release modality (no additional reimbursement for the hand-held tool; the ThermoStim probe's electrical stimulation function would be covered as an electrical-stimulation modality).; A member may receive more than one 60-day treatment course of PT as treatment of SEPARATE conditions; a surgical procedure causing the need for PT is considered initiation of a new or separate condition in a person who previously received PT for another indication, qualifying the member for an additional course of PT. (An exacerbation or flare-up of a chronic illness is NOT considered a new incident of illness.). Applies to 29 codes: 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97124, 97140, 97161, 97162, 97163, 97164, 97530, 97535, 97542, 97760, 97761.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Ongoing, written plan of care of sufficient detail, including appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment.; Determination by the member's licensed health care practitioner that the member's condition can improve significantly based on physical measures (e.g., AROM, strength, function, or subjective report of pain level) within one month of the date therapy begins.; Documentation requirements per Appendix A of the bulletin (referenced).
Trap
Policy exclusions and limitations: Experimental/investigational/unproven: Adhesion removal physical therapy for bowel obstructions.; Experimental/investigational/unproven: Applied Functional Science.; Experimental/investigational/unproven: Blood flow restriction therapy.; Experimental/investigational/unproven: Dynamic Movement Intervention.; Not covered: Kinesio taping for back pain, radicular pain syndromes, and other back-related conditions.; Not covered: Kinesio taping for lower extremity spasticity, meralgia paresthetica, post-operative subacromial decompression, wrist injury, prevention of ankle sprains, and all other indications.; Not covered: McConnell taping for knee pain, low back pain, and all other indications.; Experimental/investigational/unproven: 'Hands-free' ultrasound and low-frequency sound (infrasound).; Experimental/investigational/unproven: Hivamat therapy (deep oscillation therapy).; Experimental/investigational/unproven: Interactive Metronome program.; Experimental/investigational/unproven: Low-dye strapping for the treatment of stress fracture of the ankle.; Experimental/investigational/unproven: MEDEK therapy.; Experimental/investigational/unproven: RomTech PortableConnect.; Experimental/investigational/unproven: Strapping of the chest and/or hip for the treatment of pain and improvement of posture.; Experimental/investigational/unproven: Ultrasound therapy for the treatment of Dupuytren's contracture.; Experimental/investigational/unproven: Virtual reality facilitated gait training.; No reliable data demonstrate superiority over standard PT, so it is NOT medically necessary to go out of network for these specific methods when standard PT is available in-network: McKenzie Method of Mechanical Diagnosis and Therapy.; No reliable data demonstrate superiority over standard PT, so it is NOT medically necessary to go out of network for these specific methods when standard PT is available in-network: Muldowney Method of Physical Therapy.; No reliable data demonstrate superiority over standard PT, so it is NOT medically necessary to go out of network for these specific methods when standard PT is available in-network: Muscle Activation Techniques (MAT).; No reliable data demonstrate superiority over standard PT, so it is NOT medically necessary to go out of network for these specific methods when standard PT is available in-network: Postural Restoration Form of Physical Therapy.; Not medically necessary: Physical therapy in asymptomatic persons or in persons without an identifiable clinical condition.; Not medically necessary: Physical therapy in persons whose condition is neither regressing nor improving.; Not medically necessary: Once therapeutic benefit has been achieved, or a home exercise program could be used for further gains, continuing supervised physical therapy.; Not covered (Instrumental Activities of Daily Living - IADL, because not considered treatment of disease), including but not limited to: community living skills (e.g., balancing a checkbook, use of public transportation); home management skills (e.g., meal preparation, laundry); leisure activities (hobbies, sports, recreation of all types even if suggested as part of a PT treatment plan); motor vehicle driving evaluations and driving instruction (automobiles, trucks, motorcycles, bicycles); personal safety preparedness.; Not covered: Sports-related rehabilitation or other similar avocational activities (continued treatment for sports-related injuries to improve above and beyond normal ability to perform ADLs), because not considered treatment of disease - including but not limited to baseball pitching/throwing, cheerleading, golfing, martial arts of all types, organized football/baseball/basketball/soccer/lacrosse/swimming/track and field at college/high school/other school or community setting, professional and amateur tennis, professional and amateur/hobby/academic dance, and competitive weightlifting and similar activities.; Not covered (non-skilled services): Passive range of motion (PROM) treatment that is not specifically part of a restorative program related to loss of function.; Not covered (non-skilled services): Services that maintain function by using routine, repetitive, and reinforced procedures after initial teaching.; Not covered (non-skilled services): Most situations involving general conditioning, recovery from acute medical/surgical illness causing deconditioning, or increased general ability to exercise or walk.; Not covered (non-skilled services): Services that can be safely and effectively furnished by non-skilled personnel.; Plan exclusion: Standard Aetna policies exclude coverage for educational training or services; under plans with this exclusion, physical therapy is not covered when provided in educational settings (check benefit plan descriptions).; Benefit limit: In Aetna HMO plans the PT benefit is typically limited to a 60-day treatment period per specific condition (applied per calendar year, contract year, or as a lifetime limitation depending on plan design); some plans instead define the benefit by a number of treatment sessions covered per year regardless of condition or number of courses (check benefit plan descriptions).; Maintenance care (intended to preserve present level of function and/or prevent regression; begins when therapeutic goals are achieved or no further significant progress is made/reasonably seen, e.g., a plateau of four weeks or a lesser generally accepted period) is not covered once therapeutic benefit has been achieved or a home exercise program could be used for further gains. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0325 — Physical Therapy

Coverage criteria

  • Physical therapy (PT) is considered medically necessary when ALL of the following criteria are met (criteria 1-5 below).
  • Functional improvement / maintenance-program criterion (ONE of): the member's licensed health care practitioner has determined that the member's condition can improve significantly based on physical measures (e.g., active range of motion (AROM), strength, function, or subjective report of pain level) within one month of the date that therapy begins; OR the proposed therapy services are necessary for establishment of a safe and effective maintenance program that the member will perform WITHOUT ongoing skilled therapy services. These services must be proposed for treatment of a specific illness or injury.
  • Expectation of significant improvement: PT services are intended to cover only episodes of therapy for situations where there must be a reasonable expectation that the member's condition will improve significantly in a reasonable and generally predictable period of time.
  • Provider qualification: PT services must be performed by a duly licensed and certified (if applicable) PT provider, and all services must be within the applicable scope of practice for the provider in their licensed jurisdiction where services are provided.
  • Complexity and supervision: services must be of the complexity and nature requiring performance by a licensed professional therapist, OR provided under supervision by a licensed ancillary person as permitted under state laws. Services may be provided personally by physicians and performed by personnel under their direct supervision as permitted under state law; HOWEVER, because physicians are not licensed as physical therapists, they may NOT directly supervise physical therapy assistants.
  • Written plan of care: PT must be provided in accordance with an ongoing, written plan of care, of sufficient detail and including appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment.
  • Covered conditions: PT may be indicated for treatment of muscle weakness, limitations in range of motion, neuromuscular conditions, musculoskeletal conditions, lymphedema, and for selected training of patients in specific techniques and exercises for their own continued use at home. Generally covered for members with eligible conditions requiring the skills of a physical therapist, including impairments in body functions/structures, activity limitations, participation restrictions, need for management plan and plan of care, performance enhancement, transitions to different roles or settings, and risk factors for developing impairments.
  • Home-based physical therapy is considered medically necessary in selected cases based upon the member's needs - i.e., to address the member's functional performance and functional needs in the home environment, or as part of the transition from skilled therapy to a maintenance program.
  • Augmented soft tissue mobilization (use of hand-held tools for myofascial release; e.g., the Dynatronics ThermoStim probe) is considered medically necessary and covered as a standard myofascial release modality (no additional reimbursement for the hand-held tool; the ThermoStim probe's electrical stimulation function would be covered as an electrical-stimulation modality).
  • A member may receive more than one 60-day treatment course of PT as treatment of SEPARATE conditions; a surgical procedure causing the need for PT is considered initiation of a new or separate condition in a person who previously received PT for another indication, qualifying the member for an additional course of PT. (An exacerbation or flare-up of a chronic illness is NOT considered a new incident of illness.)

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • Ongoing, written plan of care of sufficient detail, including appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment.
  • Determination by the member's licensed health care practitioner that the member's condition can improve significantly based on physical measures (e.g., AROM, strength, function, or subjective report of pain level) within one month of the date therapy begins.
  • Documentation requirements per Appendix A of the bulletin (referenced).

Frequently asked questions

When does Aetna cover Physical Therapy (CPT 97010), and what gets it denied?
Aetna covers physical therapy as medically necessary when a licensed practitioner expects significant functional improvement within about a month (or needs to establish a self-managed maintenance program), the care is skilled, follows a written plan of care, and treats a specific illness/injury; coverage stops once therapeutic goals are met or a home exercise program could sustain gains. Many methods/devices are experimental/investigational or not covered (e.g., Kinesio/McConnell taping, blood flow restriction therapy, MEDEK, virtual reality gait training), and IADL, sports/avocational rehab, non-skilled, and maintenance care are excluded; HMO plans typically cap PT at a 60-day course per condition. The bulletin is silent on whether precertification/prior authorization is required. Coverage criteria include: Physical therapy (PT) is considered medically necessary when ALL of the following criteria are met (criteria 1-5 below).; Functional improvement / maintenance-program criterion (ONE of): the member's licensed health care practitioner has determined that the member's condition can improve significantly based on physical measures (e.g., active range of motion (AROM), strength, function, or subjective report of pain level) within one month of the date that therapy begins; OR the proposed therapy services are necessary for establishment of a safe and effective maintenance program that the member will perform WITHOUT ongoing skilled therapy services. These services must be proposed for treatment of a specific illness or injury.; Expectation of significant improvement: PT services are intended to cover only episodes of therapy for situations where there must be a reasonable expectation that the member's condition will improve significantly in a reasonable and generally predictable period of time.; Provider qualification: PT services must be performed by a duly licensed and certified (if applicable) PT provider, and all services must be within the applicable scope of practice for the provider in their licensed jurisdiction where services are provided.; Complexity and supervision: services must be of the complexity and nature requiring performance by a licensed professional therapist, OR provided under supervision by a licensed ancillary person as permitted under state laws. Services may be provided personally by physicians and performed by personnel under their direct supervision as permitted under state law; HOWEVER, because physicians are not licensed as physical therapists, they may NOT directly supervise physical therapy assistants.; Written plan of care: PT must be provided in accordance with an ongoing, written plan of care, of sufficient detail and including appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment.; Covered conditions: PT may be indicated for treatment of muscle weakness, limitations in range of motion, neuromuscular conditions, musculoskeletal conditions, lymphedema, and for selected training of patients in specific techniques and exercises for their own continued use at home. Generally covered for members with eligible conditions requiring the skills of a physical therapist, including impairments in body functions/structures, activity limitations, participation restrictions, need for management plan and plan of care, performance enhancement, transitions to different roles or settings, and risk factors for developing impairments.; Home-based physical therapy is considered medically necessary in selected cases based upon the member's needs - i.e., to address the member's functional performance and functional needs in the home environment, or as part of the transition from skilled therapy to a maintenance program.; Augmented soft tissue mobilization (use of hand-held tools for myofascial release; e.g., the Dynatronics ThermoStim probe) is considered medically necessary and covered as a standard myofascial release modality (no additional reimbursement for the hand-held tool; the ThermoStim probe's electrical stimulation function would be covered as an electrical-stimulation modality).; A member may receive more than one 60-day treatment course of PT as treatment of SEPARATE conditions; a surgical procedure causing the need for PT is considered initiation of a new or separate condition in a person who previously received PT for another indication, qualifying the member for an additional course of PT. (An exacerbation or flare-up of a chronic illness is NOT considered a new incident of illness.). Applies to 29 codes: 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97124, 97140, 97161, 97162, 97163, 97164, 97530, 97535, 97542, 97760, 97761. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Ongoing, written plan of care of sufficient detail, including appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment.; Determination by the member's licensed health care practitioner that the member's condition can improve significantly based on physical measures (e.g., AROM, strength, function, or subjective report of pain level) within one month of the date therapy begins.; Documentation requirements per Appendix A of the bulletin (referenced). Policy exclusions and limitations: Experimental/investigational/unproven: Adhesion removal physical therapy for bowel obstructions.; Experimental/investigational/unproven: Applied Functional Science.; Experimental/investigational/unproven: Blood flow restriction therapy.; Experimental/investigational/unproven: Dynamic Movement Intervention.; Not covered: Kinesio taping for back pain, radicular pain syndromes, and other back-related conditions.; Not covered: Kinesio taping for lower extremity spasticity, meralgia paresthetica, post-operative subacromial decompression, wrist injury, prevention of ankle sprains, and all other indications.; Not covered: McConnell taping for knee pain, low back pain, and all other indications.; Experimental/investigational/unproven: 'Hands-free' ultrasound and low-frequency sound (infrasound).; Experimental/investigational/unproven: Hivamat therapy (deep oscillation therapy).; Experimental/investigational/unproven: Interactive Metronome program.; Experimental/investigational/unproven: Low-dye strapping for the treatment of stress fracture of the ankle.; Experimental/investigational/unproven: MEDEK therapy.; Experimental/investigational/unproven: RomTech PortableConnect.; Experimental/investigational/unproven: Strapping of the chest and/or hip for the treatment of pain and improvement of posture.; Experimental/investigational/unproven: Ultrasound therapy for the treatment of Dupuytren's contracture.; Experimental/investigational/unproven: Virtual reality facilitated gait training.; No reliable data demonstrate superiority over standard PT, so it is NOT medically necessary to go out of network for these specific methods when standard PT is available in-network: McKenzie Method of Mechanical Diagnosis and Therapy.; No reliable data demonstrate superiority over standard PT, so it is NOT medically necessary to go out of network for these specific methods when standard PT is available in-network: Muldowney Method of Physical Therapy.; No reliable data demonstrate superiority over standard PT, so it is NOT medically necessary to go out of network for these specific methods when standard PT is available in-network: Muscle Activation Techniques (MAT).; No reliable data demonstrate superiority over standard PT, so it is NOT medically necessary to go out of network for these specific methods when standard PT is available in-network: Postural Restoration Form of Physical Therapy.; Not medically necessary: Physical therapy in asymptomatic persons or in persons without an identifiable clinical condition.; Not medically necessary: Physical therapy in persons whose condition is neither regressing nor improving.; Not medically necessary: Once therapeutic benefit has been achieved, or a home exercise program could be used for further gains, continuing supervised physical therapy.; Not covered (Instrumental Activities of Daily Living - IADL, because not considered treatment of disease), including but not limited to: community living skills (e.g., balancing a checkbook, use of public transportation); home management skills (e.g., meal preparation, laundry); leisure activities (hobbies, sports, recreation of all types even if suggested as part of a PT treatment plan); motor vehicle driving evaluations and driving instruction (automobiles, trucks, motorcycles, bicycles); personal safety preparedness.; Not covered: Sports-related rehabilitation or other similar avocational activities (continued treatment for sports-related injuries to improve above and beyond normal ability to perform ADLs), because not considered treatment of disease - including but not limited to baseball pitching/throwing, cheerleading, golfing, martial arts of all types, organized football/baseball/basketball/soccer/lacrosse/swimming/track and field at college/high school/other school or community setting, professional and amateur tennis, professional and amateur/hobby/academic dance, and competitive weightlifting and similar activities.; Not covered (non-skilled services): Passive range of motion (PROM) treatment that is not specifically part of a restorative program related to loss of function.; Not covered (non-skilled services): Services that maintain function by using routine, repetitive, and reinforced procedures after initial teaching.; Not covered (non-skilled services): Most situations involving general conditioning, recovery from acute medical/surgical illness causing deconditioning, or increased general ability to exercise or walk.; Not covered (non-skilled services): Services that can be safely and effectively furnished by non-skilled personnel.; Plan exclusion: Standard Aetna policies exclude coverage for educational training or services; under plans with this exclusion, physical therapy is not covered when provided in educational settings (check benefit plan descriptions).; Benefit limit: In Aetna HMO plans the PT benefit is typically limited to a 60-day treatment period per specific condition (applied per calendar year, contract year, or as a lifetime limitation depending on plan design); some plans instead define the benefit by a number of treatment sessions covered per year regardless of condition or number of courses (check benefit plan descriptions).; Maintenance care (intended to preserve present level of function and/or prevent regression; begins when therapeutic goals are achieved or no further significant progress is made/reasonably seen, e.g., a plateau of four weeks or a lesser generally accepted period) is not covered once therapeutic benefit has been achieved or a home exercise program could be used for further gains. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Physical Therapy?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Ongoing, written plan of care of sufficient detail, including appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment.; Determination by the member's licensed health care practitioner that the member's condition can improve significantly based on physical measures (e.g., AROM, strength, function, or subjective report of pain level) within one month of the date therapy begins.; Documentation requirements per Appendix A of the bulletin (referenced).
What does Aetna exclude for Physical Therapy?
Policy exclusions and limitations: Experimental/investigational/unproven: Adhesion removal physical therapy for bowel obstructions.; Experimental/investigational/unproven: Applied Functional Science.; Experimental/investigational/unproven: Blood flow restriction therapy.; Experimental/investigational/unproven: Dynamic Movement Intervention.; Not covered: Kinesio taping for back pain, radicular pain syndromes, and other back-related conditions.; Not covered: Kinesio taping for lower extremity spasticity, meralgia paresthetica, post-operative subacromial decompression, wrist injury, prevention of ankle sprains, and all other indications.; Not covered: McConnell taping for knee pain, low back pain, and all other indications.; Experimental/investigational/unproven: 'Hands-free' ultrasound and low-frequency sound (infrasound).; Experimental/investigational/unproven: Hivamat therapy (deep oscillation therapy).; Experimental/investigational/unproven: Interactive Metronome program.; Experimental/investigational/unproven: Low-dye strapping for the treatment of stress fracture of the ankle.; Experimental/investigational/unproven: MEDEK therapy.; Experimental/investigational/unproven: RomTech PortableConnect.; Experimental/investigational/unproven: Strapping of the chest and/or hip for the treatment of pain and improvement of posture.; Experimental/investigational/unproven: Ultrasound therapy for the treatment of Dupuytren's contracture.; Experimental/investigational/unproven: Virtual reality facilitated gait training.; No reliable data demonstrate superiority over standard PT, so it is NOT medically necessary to go out of network for these specific methods when standard PT is available in-network: McKenzie Method of Mechanical Diagnosis and Therapy.; No reliable data demonstrate superiority over standard PT, so it is NOT medically necessary to go out of network for these specific methods when standard PT is available in-network: Muldowney Method of Physical Therapy.; No reliable data demonstrate superiority over standard PT, so it is NOT medically necessary to go out of network for these specific methods when standard PT is available in-network: Muscle Activation Techniques (MAT).; No reliable data demonstrate superiority over standard PT, so it is NOT medically necessary to go out of network for these specific methods when standard PT is available in-network: Postural Restoration Form of Physical Therapy.; Not medically necessary: Physical therapy in asymptomatic persons or in persons without an identifiable clinical condition.; Not medically necessary: Physical therapy in persons whose condition is neither regressing nor improving.; Not medically necessary: Once therapeutic benefit has been achieved, or a home exercise program could be used for further gains, continuing supervised physical therapy.; Not covered (Instrumental Activities of Daily Living - IADL, because not considered treatment of disease), including but not limited to: community living skills (e.g., balancing a checkbook, use of public transportation); home management skills (e.g., meal preparation, laundry); leisure activities (hobbies, sports, recreation of all types even if suggested as part of a PT treatment plan); motor vehicle driving evaluations and driving instruction (automobiles, trucks, motorcycles, bicycles); personal safety preparedness.; Not covered: Sports-related rehabilitation or other similar avocational activities (continued treatment for sports-related injuries to improve above and beyond normal ability to perform ADLs), because not considered treatment of disease - including but not limited to baseball pitching/throwing, cheerleading, golfing, martial arts of all types, organized football/baseball/basketball/soccer/lacrosse/swimming/track and field at college/high school/other school or community setting, professional and amateur tennis, professional and amateur/hobby/academic dance, and competitive weightlifting and similar activities.; Not covered (non-skilled services): Passive range of motion (PROM) treatment that is not specifically part of a restorative program related to loss of function.; Not covered (non-skilled services): Services that maintain function by using routine, repetitive, and reinforced procedures after initial teaching.; Not covered (non-skilled services): Most situations involving general conditioning, recovery from acute medical/surgical illness causing deconditioning, or increased general ability to exercise or walk.; Not covered (non-skilled services): Services that can be safely and effectively furnished by non-skilled personnel.; Plan exclusion: Standard Aetna policies exclude coverage for educational training or services; under plans with this exclusion, physical therapy is not covered when provided in educational settings (check benefit plan descriptions).; Benefit limit: In Aetna HMO plans the PT benefit is typically limited to a 60-day treatment period per specific condition (applied per calendar year, contract year, or as a lifetime limitation depending on plan design); some plans instead define the benefit by a number of treatment sessions covered per year regardless of condition or number of courses (check benefit plan descriptions).; Maintenance care (intended to preserve present level of function and/or prevent regression; begins when therapeutic goals are achieved or no further significant progress is made/reasonably seen, e.g., a plateau of four weeks or a lesser generally accepted period) is not covered once therapeutic benefit has been achieved or a home exercise program could be used for further gains. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0325 — Physical Therapy

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0325 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.