Physical Therapy (PT)

Policy ID: Y-1-066

Section: Therapy

Effective Date: July 01, 2018

Revised Date: December 20, 2024

Revision Effective Date: March 03, 2025

Last Reviewed: January 14, 2025

Applies To: Commercial and Medicaid Expansion

Description

Physical medicine and rehabilitation is a medical specialty concerned with diagnosis, evaluation, and management of persons with physical impairment and disability. This specialty involves diagnosis and treatment of individuals with painful or functionally limiting conditions, the management of comorbidities and co-impairments.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; OR
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage for physical medicine is determined according to individual or group customer benefits.

Physical medicine is considered medically necessary when ALL of the following criteria are met;

Expectation of restoring the individual's level or function that has been lost or reduced by injury or illness; and
Treatment plans must be maintained in the medical record and available upon request.

Procedure Codes

4018F

90901

95851

95852

95992

96125

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97035

97036

97039

97110

97112

97113

97116

97124

97129

97130

97139

97140

97150

97161

97162

97163

97164

97530

97533

97535

97537

97542

97545

97546

97597

97598

97750

97755

97760

97761

97763

97799

99374

99375

99377

99378

99380

G0181

G0182

G0237

G0238

G0239

G0283

S8948

S8950

S9123

S9124

S9125

S9128

S9129

S9131

T1021

T1025

T1026

Maintenance Therapy

Policy Application

Physical medicine services performed repetitively to maintain a level of function are not eligible for coverage unless the member has Habilitative services benefits.

A maintenance program consists of activities that preserve the individual's present level of function and prevent regression of that function. These services would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness.

Maintenance begins when the therapeutic goals of a treatment plan have been achieved, and no additional functional progress is apparent or expected to occur.

Procedure Code

S8990

Habilitative Therapy

Habilitative therapy services may be considered medically necessary when the following criteria are met:

Ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury; and/or
Includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.

Note:

Habilitative therapy is not eligible for payment unless the member has a habilitative benefit.

*Spinal manipulation is not considered a habilitative service

Habilitative services not meeting the criteria as outlined in this policy are considered not medically necessary.

Procedure Codes

4018F

90901

95851

95852

95992

96125

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97035

97036

97039

97110

97112

97113

97116

97124

97129

97130

97139

97140

97150

97161

97162

97163

97164

97530

97533

97535

97537

97542

97545

97546

97550

97551

97552

97597

97598

97750

97755

97760

97761

97763

97799

99374

99375

99377

99378

99380

G0181

G0182

G0237

G0238

G0239

G0283

S8948

S8950

S9123

S9124

S9125

S9128

S9129

S9131

T1021

T1025

T1026

Supervised Modalities

Supervised modalities do not require direct one-on-one individual contact with the individual by the provider. These are not time-based codes.

Procedure Codes

97012

97014

97016

97018

97022

97024

97026

Vasopneumatic Compression

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Vasopneumatic compression is considered medically necessary for the following conditions;

Edema of the extremities; or
Hematoma of the leg; or
Lymphedema of the arm; or
Lymphedema of the leg; or
Venous insufficiency or venous stasis disorder

Vasopneumatic compression not meeting the criteria as indicated in this policy is considered not medically necessary.

Vasopneumatic compression is considered a supervised modality and is not considered time-based. It should be reported only once per treatment session, regardless of the number of areas treated or the length of time required to complete treatment.

Procedure Code

97016

Infrared Therapy

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service

The use of infrared and near-infrared light and heat, including monochromatic infrared energy, when used as a physical medicine modality for the treatment of diabetic and/or non-diabetic peripheral sensory neuropathy and wounds and/or ulcers of the skin and/or subcutaneous tissues is considered not medically necessary.

Procedure Code

97026

Constant Attendance Modalities

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Constant attendance modalities are those modalities that require direct one-on-one contact with the individual by the provider. Documentation must include the amount of time spent in providing all aspects of this service.

When two (2) constant attendance modalities are performed at the same time, using one device, the code representing the primary modality must be reported.

Procedure Codes

97032

97033

97034

97035

97036

97039

Aquatic Therapy

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service

Aquatic therapy must be performed with the expectation of restoring an individuals level of function that has been lost or reduced by injury or illness. Aquatic therapy performed to maintain a level of function is considered to be a maintenance program.

A provider must have direct (one to one) individual contact with the individual when reporting aquatic therapy.

Before beginning an aquatic therapy program, the provider must prepare a treatment plan that includes short-term and long-term goals that the individual can be reasonably expected to accomplish through the aquatic therapy program and the specific methods chosen.

Procedure Codes

97034

97113

Gait Training

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Gait training may be considered medically necessary for the following indications:

Foot drop resulting from stroke; or
Herniated disc(s); or
Ankle, knee and/or hip replacement; or
Traumatic amputations of the toe(s)

Documentation for gait training must demonstrate that the individual's gait was improved either by lengthening the gait or increasing the frequency of cadence lower-extremity.

Gait training not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

97116

97760

97761

97763

Vestibular Rehabilitation Therapy

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

A vestibular rehabilitation program typically last 45 minutes per session and is prescribed 1-2 times per week. In general, individuals remain in the program 4-8 weeks.

A vestibular rehabilitation program may be considered medically necessary for individuals with vertigo, disequilibrium, and balance deficits related to the following conditions:

Peripheral vestibular disorders (e.g., labyrinthitis, neuritis, benign paroxysmal positional vertigo, post vestibular surgical symptoms, and bilateral vestibular loss); or
Mixed {peripheral and central vestibular disorders; or
Central causes of vertigo (e.g., CVA, multiple sclerosis, and mild traumatic brain injury).

A vestibular rehabilitation program not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Code

S9476

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service

The following services are considered experimental/investigational and, therefore, non-covered, because the safety and effectiveness of this service cannot be established by published peer-reviewed literature. This is not an all inclusive list:

Equestrian/Hippotherapy
Low-Level Laser Therapy (Cold Laser Therapy)

Procedure Codes

S8940

S8948

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code: 97016

I87.2

I87.8

I87.9

I89.0

I97.2

M79.81

M79.89

Q82.0

R60.0

R60.1

R60.9

S70.10XA

S70.11XA

S70.12XA

S80.10XA

S80.11XA

S80.12XA

Covered Diagnosis Codes for Procedure Code: 97116

M51.27

R26.9

R62.50

S98.111A

S98.111D

S98.111S

S98.112A

S98.112D

S98.112S

S98.121A

S98.121D

S98.121S

S98.122A

S98.122D

S98.122S

S98.131A

S98.131D

S98.131S

S98.132A

S98.132D

S98.132S

S98.141A

S98.141D

S98.141S

S98.142A

S98.142D

S98.142S

S98.211A

S98.211D

S98.211S

S98.212A

S98.212D

S98.212S

S98.221D

S98.221S

S98.222A

S98.222D

S98.222S

Z96.641

Z96.642

Z96.643

Z96.649

Z96.651

Z96.652

Z96.653

Z96.659

Z96.661

Z96.662

Z96.669

F82

G10

G20.A1

G20.A2

G35

G71.11

G80.0

G80.1

G80.2

G80.3

G80.4

G80.8

G80.9

G95.20

G95.29

H51.8

I63.81

I63.89

I63.9

I69.153

I69.154

I69.353

I69.354

M08.00

M16.11

M16.12

M16.2

M17.11

M17.12

M17.2

M19.071

M19.072

M21.70

M21.721

M21.722

M25.551

M25.552

M25.561

M25.562

M48.02

M50.10

M54.16

M62.81

M62.89

M79.604

M79.605

M79.661

M79.662

M99.05

P07.36

P07.39

Q05.2

Q05.9

R26.2

R26.89

R41.840

R50.10

R53.1

R62.50

S06.9X6A

S06.9X6D

S06.9X6S

S06.9X9A

S06.9X9D

S06.9X9S

S50.892D

S72.051A

S72.051B

S72.051C

S72.051D

S72.051E

S72.051F

S72.051G

S72.051H

S72.051J

S72.051K

S72.051M

S72.051N

S72.051P

S72.051Q

S72.051R

S72.051S

S72.052A

S72.052B

S72.052C

S72.052D

S72.052E

S72.052F

S72.052G

S72.052H

S72.052J

S72.052K

S72.052M

S72.052N

S72.052P

S72.052Q

S72.052R

S72.052S

S72.321A

S72.321B

S72.321C

S72.321D

S72.321E

S72.321F

S72.321G

S72.321H

S72.321J

S72.321K

S72.321M

S72.321N

S72.321P

S72.321Q

S72.321R

S72.321S

S82.142A

S82.142B

S82.142C

S82.142D

S82.142E

S82.142F

S82.142G

S82.142H

S82.142J

S82.142K

S82.142M

S82.142N

S82.142P

S82.142Q

S82.142R

S82.142S

S82.201A

S82.201B

S82.201C

S82.201D

S82.201E

S82.201F

S82.201G

S82.201H

S82.201J

S82.201K

S82.201M

S82.201N

S82.201P

S82.201Q

S82.201R

S82.201S

S82.61XA

S82.61XB

S82.61XC

S82.61XD

S82.61XE

S82.61XF

S82.61XG

S82.61XH

S82.61XJ

S82.61XK

S82.61XM

S82.61XN

S82.61XP

S82.61XQ

S82.61XR

S82.61XS

S82.821A

S82.821B

S82.821C

S82.821D

S82.821E

S82.821F

S82.821G

S82.821H

S82.821J

S82.821K

S82.821M

S82.821N

S82.821P

S82.821Q

S82.821R

S82.821S

S82.892A

S82.892B

S82.892C

S82.892D

S82.892E

S82.892F

S82.892G

S82.892H

S82.892J

S82.892K

S82.892M

S82.892N

S82.892P

S82.892Q

S82.892R

S82.892S

S83.512A

S83.512B

S83.512C

S83.512D

S83.512E

S83.512F

S83.512G

S83.512H

S83.512J

S83.512K

S83.512M

S83.512N

S83.512P

S83.512Q

S83.512R

S83.512S

S86.012A

S86.012B

S86.012C

S86.012D

S86.012E

S86.012F

S86.012G

S86.012H

S86.012J

S86.012K

S86.012M

S86.012N

S86.012P

S86.012Q

S86.012R

S86.012S

S86.401A

S86.401B

S86.401C

S86.401D

S86.401E

S86.401F

S86.401G

S86.401H

S86.401J

S86.401K

S86.401M

S86.401N

S86.401P

S86.401Q

S86.401R

S86.401S

Z08

Z09

Z47.89

Z98.890

Covered Diagnosis Codes for Procedure Code: S9476

G35

H81.10

H81.11

H81.12

H81.13

H81.20

H81.21

H81.22

H81.23

H81.311

H81.312

H81.313

H81.319

H81.391

H81.392

H81.393

H81.399

H81.4

H83.01

H83.02

H83.03

H83.09

I63.30

I63.311

I63.312

I63.313

I63.321

I63.322

I63.323

I63.329

I63.331

I63.332

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020

Updated language

Internal Medical Policy Committee 3-17-2021 Revision updated language and coding update

Added procedure code: S8940.

Internal Medical Policy Committee 3-23-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 7-21-2022 Revision with coding updates - Effective September 05, 2022

Removed procedure codes: 97165; 97166; 97167; 97168; and S8990
Added procedure codes: 4018F; 90901; 96125; 97129; 97130; 97545; 97546; 97755; 99339; 99340;99374; 99375; 99377; 99378; 99380; G0181; G0182; G0237; G0238; G0239; S9123; S9124; S9125; S9128; S9129; S9131; T1021; T1025; T1026.

Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 02, 2022

Removed procedure codes 99339; 99340; and
Added procedure codes 97597; and 97598.

Internal Medical Policy Committee 5-23-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 11-15-2023 Coding Update- Effective January 01, 2024

Added diagnosis codes R26.9 and R62.50 for procedure code 97116.

Internal Medical Policy Committee 3-19-2024 Revision- Effective May 06, 2024

Revised criteria; and
Added Policy Application; and
Added procedure code 97116.

Internal Medical Policy Committee 7-16-2024 Coding update - Effective September 02, 2024

Added procedure codes 97550; 97551 and 97552 to Habilitative section.

Internal Medical Policy Committee 11-19-2024 Coding Update - Effective January 06, 2025

Added diagnosis codes for procedure code 97116:
F82, G10; G20.A1; G20.A2; G35; G71.11; G80.0; G80.1; G80.2; G80.3; G80.4; G80.8; G80.9; G95.20; G95.29; H51.8; I63.81; I63.89; I63.9; I69.153; I69.154; I69.353; I69.354; M08.00; M16.11; M16.12; M16.2; M17.11; M17.12; M17.2; M19.071; M19.072; M21.70; M21.721; M21.722; M25.551; M25.552; M25.561; M25.562; M48.02; M50.10; M54.16; M62.81; M62.89; M79.604; M79.605; M79.661; M79.662; M99.05; P07.36; P07.39; Q05.2; Q05.9; R26.2; R26.89; R41.840; R50.10; R53.1; R62.50; S06.9X6A; S06.9X6D; S06.9X6S; S06.9X9A; S06.9X9D; S06.9X9S; S50.892D; S72.051A; S72.051B; S72.051C; S72.051D; S72.051E; S72.051F; S72.051G; S72.051H; S72.051J; S72.051K; S72.051M; S72.051N; S72.051P; S72.051Q, S72.051R; S72.051S;, S72.052A; S72.052B; S72.052C; S72.052D; S72.052E; S72.052F; S72.052G; S72.052H; S72.052J; S72.052K; S72.052M; S72.052N; S72.052P; S72.052Q; S72.052R; S72.052S; S72.321A; S72.321B; S72.321C; S72.321D; S72.321E; S72.321F; S72.321G; S72.321H; S72.321J; S72.321K; S72.321M; S72.321N; S72.321P; S72.321Q; S72.321R; S72.321S; S82.142A; S82; S82.142B; S82.142C; S82.142D; S82.142E; S82.142F; S82.142G; S82.142H; S82.142J; S82.142K; S82.142M; S82.142N; S82.142P; S82.142Q; S82.142R; S82.142S; S82.201A; S82.201B; S82.201C; S82.201D; S82.201E; S82.201F; S82.201G; S82.201H; S82.201J; S82.201K; S82.201M; S82.201N; S82.201P; S82.201Q; S82.201R; S82.201S; S82.61XA; S82.61XB; S82.61XC; S82.61XD; S82.61XE; S82.61XF; S82.61XG; S82.61XH; S82.61XJ; S82.61XK; S82.61XM; S82.61XN; S82.61XP; S82.61XQ; S82.61XR; S82.61XS; S82.821A; S82.821B; S82.821C; S82.821D; S82.821E; S82.821F; S82.821G; S82.821H; S82.821J; S82.821K; S82.821M; S82.821N, S82.821P, S82.821Q; S82.821R; S82.821S; S82.892A; S82.892B; S82.892C; S82.892D; S82.892E; S82.892F; S82.892G; S82.892H; S82.892J; S82.892K; S82.892M; S82.892N; S82.892P; S82.892Q; S82.892R; S82.892S; S83.512A; S83.512B; S83.512C; S83.512D; S83.512E; S83.512F; S83.512G; S83.512H; S83.512J; S83.512K; S83.512M; S83.512N; S83.512P; S83.512Q; S83.512R; S83.512S; S86.012A; S86.012B; S86.012C; S86.012D; S86.012E; S86.012F; S86.012G; S86.012H; S86.012J; S86.012K; S86.012M; S86.012N; S86.012P; S86.012Q; S86.012R; S86.012S; S86.401A; S86.401B; S86.401C; S86.401D; S86.401E; S86.401F; S86.401G; S86.401H; S86.401J; S86.401K; S86.401M; S86.401N; S86.401P; S86.401Q; S86.401R; S86.401S; Z08; Z09; Z47.89; and Z98.890; and
Updated Policy Application

Internal Medical Policy Committee 1-14-2025 Annual Review - no changes in criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: Y-1-065

Section: Therapy

Effective Date: July 01, 2018

Revised Date: November 21, 2024

Revision Effective Date: January 06, 2025

Last Reviewed: November 19, 2024

Archived Date: March 02, 2025

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Coverage for physical medicine is determined according to individual or group customer benefits.

Policy Application

Physical medicine is considered medically necessary when ALL of the following criteria are met;

Expectation of restoring the individual's level or function that has been lost or reduced by injury or illness; and
Treatment plans must be maintained in the medical record and available upon request.

Procedure Codes

4018F

90901

95851

95852

95992

96125

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97035

97036

97039

97110

97112

97113

97116

97124

97129

97130

97139

97140

97150

97161

97162

97163

97164

97530

97533

97535

97537

97542

97545

97546

97597

97598

97750

97755

97760

97761

97763

97799

99374

99375

99377

99378

99380

G0181

G0182

G0237

G0238

G0239

G0283

S8948

S8950

S9123

S9124

S9125

S9128

S9129

S9131

T1021

T1025

T1026

Maintenance Therapy

Physical medicine services performed repetitively to maintain a level of function are not eligible for coverage unless the member has Habilitative services benefits.

Maintenance begins when the therapeutic goals of a treatment plan have been achieved, and no additional functional progress is apparent or expected to occur.

Procedure Code

S8990

Habilitative Therapy

Habilitative therapy services may be considered medically necessary when the following criteria are met:

Ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury; and/or

Includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.

Note:

Habilitative therapy is not eligible for payment unless the member has a habilitative benefit.

*Spinal manipulation is not considered a habilitative service

Habilitative services not meeting the criteria as outlined in this policy are considered not medically necessary.

Procedure Codes

4018F

90901

95851

95852

95992

96125

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97035

97036

97039

97110

97112

97113

97116

97124

97129

97130

97139

97140

97150

97161

97162

97163

97164

97530

97533

97535

97537

97542

97545

97546

97550

97551

97552

97597

97598

97750

97755

97760

97761

97763

97799

99374

99375

99377

99378

99380

G0181

G0182

G0237

G0238

G0239

G0283

S8948

S8950

S9123

S9124

S9125

S9128

S9129

S9131

T1021

T1025

T1026

Supervised Modalities

Supervised modalities do not require direct one-on-one individual contact with the individual by the provider. These are not time-based codes.

Procedure Codes

97012

97014

97016

97018

97022

97024

97026

Vasopneumatic Compression

Vasopneumatic compression is considered medically necessary for the following conditions;

Edema of the extremities; or
Hematoma of the leg; or
Lymphedema of the arm; or
Lymphedema of the leg; or
Venous insufficiency or venous stasis disorder

Vasopneumatic compression not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Code

97016

Infrared Therapy

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service

Procedure Code

97026

Constant Attendance Modalities

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service

When two (2) constant attendance modalities are performed at the same time, using one device, the code representing the primary modality must be reported.

Procedure Codes

97032

97033

97034

97035

97036

97039

Aquatic Therapy

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service

A provider must have direct (one to one) individual contact with the individual when reporting aquatic therapy.

Procedure Codes

97034

97113

Gait Training

Gait training may be considered medically necessary for the following indications:

Foot drop resulting from stroke; or
Herniated disc(s); or
Ankle, knee and/or hip replacement; or
Traumatic amputations of the toe(s)

Documentation for gait training must demonstrate that the individual's gait was improved either by lengthening the gait or increasing the frequency of cadence lower-extremity.

Gait training not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

97116

97760

97761

97763

Vestibular Rehabilitation Therapy

A vestibular rehabilitation program typically last 45 minutes per session and is prescribed 1-2 times per week. In general, individuals remain in the program 4-8 weeks.

A vestibular rehabilitation program may be considered medically necessary for individuals with vertigo, disequilibrium, and balance deficits related to the following conditions:

Peripheral vestibular disorders (e.g., labyrinthitis, neuritis, benign paroxysmal positional vertigo, post vestibular surgical symptoms, and bilateral vestibular loss); or
Mixed {peripheral and central vestibular disorders; or
Central causes of vertigo (e.g., CVA, multiple sclerosis, and mild traumatic brain injury).

A vestibular rehabilitation program not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Code

S9476

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service

Equestrian/Hippotherapy
Low-Level Laser Therapy (Cold Laser Therapy)

Procedure Codes

S8940

S8948

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code: 97016

I87.2

I87.8

I87.9

I89.0

I97.2

M79.81

M79.89

Q82.0

R60.0

R60.1

R60.9

S70.10XA

S70.11XA

S70.12XA

S80.10XA

S80.11XA

S80.12XA

Covered Diagnosis Codes for Procedure Code: 97116

M51.27

R26.9

R62.50

S98.111A

S98.111D

S98.111S

S98.112A

S98.112D

S98.112S

S98.121A

S98.121D

S98.121S

S98.122A

S98.122D

S98.122S

S98.131A

S98.131D

S98.131S

S98.132A

S98.132D

S98.132S

S98.141A

S98.141D

S98.141S

S98.142A

S98.142D

S98.142S

S98.211A

S98.211D

S98.211S

S98.212A

S98.212D

S98.212S

S98.221D

S98.221S

S98.222A

S98.222D

S98.222S

Z96.641

Z96.642

Z96.643

Z96.649

Z96.651

Z96.652

Z96.653

Z96.659

Z96.661

Z96.662

Z96.669

F82

G10

G20.A1

G20.A2

G35

G71.11

G80.0

G80.1

G80.2

G80.3

G80.4

G80.8

G80.9

G95.20

G95.29

H51.8

I63.81

I63.89

I63.9

I69.153

I69.154

I69.353

I69.354

M08.00

M16.11

M16.12

M16.2

M17.11

M17.12

M17.2

M19.071

M19.072

M21.70

M21.721

M21.722

M25.551

M25.552

M25.561

M25.562

M48.02

M50.10

M54.16

M62.81

M62.89

M79.604

M79.605

M79.661

M79.662

M99.05

P07.36

P07.39

Q05.2

Q05.9

R26.2

R26.89

R41.840

R50.10

R53.1

R62.50

S06.9X6A

S06.9X6D

S06.9X6S

S06.9X9A

S06.9X9D

S06.9X9S

S50.892D

S72.051A

S72.051B

S72.051C

S72.051D

S72.051E

S72.051F

S72.051G

S72.051H

S72.051J

S72.051K

S72.051M

S72.051N

S72.051P

S72.051Q

S72.051R

S72.051S

S72.052A

S72.052B

S72.052C

S72.052D

S72.052E

S72.052F

S72.052G

S72.052H

S72.052J

S72.052K

S72.052M

S72.052N

S72.052P

S72.052Q

S72.052R

S72.052S

S72.321A

S72.321B

S72.321C

S72.321D

S72.321E

S72.321F

S72.321G

S72.321H

S72.321J

S72.321K

S72.321M

S72.321N

S72.321P

S72.321Q

S72.321R

S72.321S

S82.142A

S82.142B

S82.142C

S82.142D

S82.142E

S82.142F

S82.142G

S82.142H

S82.142J

S82.142K

S82.142M

S82.142N

S82.142P

S82.142Q

S82.142R

S82.142S

S82.201A

S82.201B

S82.201C

S82.201D

S82.201E

S82.201F

S82.201G

S82.201H

S82.201J

S82.201K

S82.201M

S82.201N

S82.201P

S82.201Q

S82.201R

S82.201S

S82.61XA

S82.61XB

S82.61XC

S82.61XD

S82.61XE

S82.61XF

S82.61XG

S82.61XH

S82.61XJ

S82.61XK

S82.61XM

S82.61XN

S82.61XP

S82.61XQ

S82.61XR

S82.61XS

S82.821A

S82.821B

S82.821C

S82.821D

S82.821E

S82.821F

S82.821G

S82.821H

S82.821J

S82.821K

S82.821M

S82.821N

S82.821P

S82.821Q

S82.821R

S82.821S

S82.892A

S82.892B

S82.892C

S82.892D

S82.892E

S82.892F

S82.892G

S82.892H

S82.892J

S82.892K

S82.892M

S82.892N

S82.892P

S82.892Q

S82.892R

S82.892S

S83.512A

S83.512B

S83.512C

S83.512D

S83.512E

S83.512F

S83.512G

S83.512H

S83.512J

S83.512K

S83.512M

S83.512N

S83.512P

S83.512Q

S83.512R

S83.512S

S86.012A

S86.012B

S86.012C

S86.012D

S86.012E

S86.012F

S86.012G

S86.012H

S86.012J

S86.012K

S86.012M

S86.012N

S86.012P

S86.012Q

S86.012R

S86.012S

S86.401A

S86.401B

S86.401C

S86.401D

S86.401E

S86.401F

S86.401G

S86.401H

S86.401J

S86.401K

S86.401M

S86.401N

S86.401P

S86.401Q

S86.401R

S86.401S

Z08

Z09

Z47.89

Z98.890

Covered Diagnosis Codes for Procedure Code: S9476

G35

H81.10

H81.11

H81.12

H81.13

H81.20

H81.21

H81.22

H81.23

H81.311

H81.312

H81.313

H81.319

H81.391

H81.392

H81.393

H81.399

H81.4

H83.01

H83.02

H83.03

H83.09

I63.30

I63.311

I63.312

I63.313

I63.321

I63.322

I63.323

I63.329

I63.331

I63.332

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020

Updated language

Internal Medical Policy Committee 3-17-2021 Revision updated language and coding update

Added procedure code: S8940.

Internal Medical Policy Committee 3-23-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 7-21-2022 Revision with coding updates - Effective September 05, 2022

Removed procedure codes: 97165; 97166; 97167; 97168; and S8990
Added procedure codes: 4018F; 90901; 96125; 97129; 97130; 97545; 97546; 97755; 99339; 99340;99374; 99375; 99377; 99378; 99380; G0181; G0182; G0237; G0238; G0239; S9123; S9124; S9125; S9128; S9129; S9131; T1021; T1025; T1026.

Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 02, 2022

Removed procedure codes 99339; 99340; and
Added procedure codes 97597; and 97598.

Internal Medical Policy Committee 5-23-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 11-15-2023 Coding Update- Effective January 01, 2024

Added diagnosis codes R26.9 and R62.50 for procedure code 97116.

Internal Medical Policy Committee 3-19-2024 Revision- Effective May 06, 2024

Revised criteria; and
Added Policy Application; and
Added procedure code 97116.

Internal Medical Policy Committee 7-16-2024 Coding update - Effective September 02, 2024

Added procedure codes 97550; 97551 and 97552 to Habilitative section.

Internal Medical Policy Committee 11-19-2024 Coding Update - Effective January 06, 2025

Added diagnosis codes
F82, G10, G20.A1, G20.A2, G35, G71.11, G80.0, G80.1, G80.2, G80.3, G80.4, G80.8, G80.9, G95.20, G95.29, H51.8, I63.81, I63.89, I63.9, I69.153, I69.154, I69.353, I69.354, M08.00, M16.11, M16.12, M16.2, M17.11, M17.12, M17.2, M19.071, M19.072, M21.70, M21.721, M21.722, M25.551, M25.552, M25.561, M25.562, M48.02, M50.10, M54.16, M62.81, M62.89, M79.604, M79.605, M79.661, M79.662, M99.05, P07.36, P07.39, Q05.2, Q05.9, R26.2, R26.89, R41.840, R50.10, R53.1, R62.50, S06.9X6A, S06.9X6D, S06.9X6S, S06.9X9A, S06.9X9D, S06.9X9S, S50.892D, S72.051A, S72.051B, S72.051C, S72.051D, S72.051E, S72.051F, S72.051G, S72.051H, S72.051J, S72.051K, S72.051M, S72.051N , S72.051P, S72.051Q, S72.051R, S72.051S, S72.052A, S72.052B, S72.052C, S72.052D, S72.052E, S72.052F, S72.052G, S72.052H, S72.052J, S72.052K, S72.052M, S72.052N , S72.052P, S72.052Q, S72.052R, S72.052S, S72.321A, S72.321B, S72.321C, S72.321D, S72.321E, S72.321F, S72.321G, S72.321H, S72.321J, S72.321K, S72.321M, S72.321N , S72.321P, S72.321Q, S72.321R, S72.321S, S82.142A, S82.142A, S82.142B, S82.142C, S82.142D, S82.142E, S82.142F, S82.142G, S82.142H, S82.142J, S82.142K, S82.142M, S82.142N, S82.142P, S82.142Q, S82.142R, S82.142S, S82.201A, S82.201B, S82.201C, S82.201D, S82.201E, S82.201F, S82.201G, S82.201H, S82.201J, S82.201K, S82.201M, S82.201N, S82.201P, S82.201Q, S82.201R, S82.201S, S82.61XA, S82.61XB, S82.61XC, S82.61XD, S82.61XE, S82.61XF, S82.61XG, S82.61XH, S82.61XJ, S82.61XK, S82.61XM, S82.61XN, S82.61XP, S82.61XQ, S82.61XR, S82.61XS, S82.821A, S82.821B, S82.821C, S82.821D, S82.821E, S82.821F, S82.821G, S82.821H, S82.821J, S82.821K, S82.821M, S82.821N, S82.821P, S82.821Q, S82.821R, S82.821S, S82.892A, S82.892B, S82.892C, S82.892D, S82.892E, S82.892F, S82.892G, S82.892H, S82.892J, S82.892K, S82.892M, S82.892N, S82.892P, S82.892Q, S82.892R, S82.892S, S83.512A, S83.512B, S83.512C, S83.512D, S83.512E, S83.512F, S83.512G, S83.512H, S83.512J, S83.512K, S83.512M, S83.512N, S83.512P, S83.512Q, S83.512R, S83.512S, S86.012A, S86.012B, S86.012C, S86.012D, S86.012E, S86.012F, S86.012G, S86.012H, S86.012J, S86.012K, S86.012M, S86.012N, S86.012P, S86.012Q, S86.012R, S86.012S, S86.401A, S86.401B, S86.401C, S86.401D, S86.401E, S86.401F, S86.401G, S86.401H, S86.401J, S86.401K, S86.401M, S86.401N, S86.401P, S86.401Q, S86.401R, S86.401S, Z08, Z09, Z47.89, and Z98.890 to procedure code 97116.
Updated Policy Application

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Physical Therapy (PT)

Description

Policy Application

Criteria

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Maintenance Therapy

Habilitative Therapy

Procedure Codes

Supervised Modalities

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Infrared Therapy

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Professional Statements and Societal Positions Guidelines

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Description

Criteria

Policy Application

Procedure Codes

Maintenance Therapy

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