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Covered Services and Limitations
Criteria for Coverage
Physical and Occupational Therapy services are covered if they are medically necessary and meet the following criteria:
A daily limit of five (5) units of physical therapy services and five (5) units of occupational therapy services is allowed, whether it is rehabilitative or habilitative. Some specific daily limits per procedure code apply.
Members may receive up to forty-eight (48) units of any combination of PT/OT services per rolling twelve (12) month period before a Prior Authorization Request (PAR) is required. Evaluation and orthotic services are not included in this limit. This equates to roughly twelve (12) hours of therapy services (each unit of service being equal to 15 minutes). This unit limit will be automatically enforced by the claims payment system by denying claims that exceed the limit.
Units of service exceeding the initial forty-eight (48) units are not covered without an approved PAR.
The twelve (12) month period begins when therapy is initiated. The unit limit does not roll-over to accumulate more than forty-eight (48) available units in a twelve (12) month period. Units are continually available until the limit of forty-eight (48) has been reached in a twelve (12) month period.
A member may receive outpatient physical therapy and occupational therapy services during the same period and service dates, however, duplicate therapy (the same therapy performed by both an OT and PT) may not be performed on the same dates of service. Duplicated services (in general, and those overlapped between PTs and OTs) are not covered.
Colorado Department of Health Care Policy & Financing
Physical and Occupational Therapy Billing Manual