OT may be considered medically necessary for individuals who meet ALL of the following criteria:
- The therapy is aimed at improving, adapting or restoring functions of an individual who has been impaired or permanently lost as a result of physical disability due to illness, injury, congenital anomaly, or prior therapeutic intervention; and
- Achieve a specific diagnosis-related goal for an individual who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time based on the qualified OT assessment of the individual’s restoration potential and unique medical condition; and
- Specific, effective and reasonable treatment for the individual’s diagnosis and physical condition; and
- The services are delivered by a qualified provider of OT services. A qualified provider is an individual who is licensed, where required, and performs within the scope of licensure.
A typical treatment plan consists of up to one (1) hour sessions and up to four (4) physical medicine procedures per date of service and includes ANY of the following:
- Modalities; or
- Therapeutic procedures; or
- Tests and measurements; or
- Muscle range of motion (ROM) testing; or
- Orthotic management and prosthetic management.
Exceptions include [standardized cognitive performance testing per hour and work hardening/conditioning; initial two (2) hours. Each additional hour of work hardening/conditioning will be considered exceeding the limitation; and is considered not medically necessary.
Duplicate therapy is considered not medically necessary. Example: An individual receiving therapy services from two (2) different providers treating the same condition.