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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Prior Authorization for Therapy Services

Prior authorization is required for all therapy services. The following criteria must be met for PA of physical therapy, occupational therapy, respiratory therapy, and speech pathology when it is provided outside the exceptions stated below:

    • Written evidence of physician involvement and personal patient evaluation will be required to document the acute medical needs. Therapy must be ordered by a qualifying provider (see individual policy sections for qualifying providers).
    • A current plant of treatment, developed sixty (60) to ninety (90) days from the date of the PA submission, must include clearly stated and measurable goals and progress.
    • Therapies must be provided by a qualified therapist or a qualified assistant under direct supervision of a therapist, as appropriate.
    • Therapy must be of such a level of complexity and sophistication and the condition of the member must be such that the judgment, knowledge, and skills of a qualified therapist are required.
    • Therapy must be medically necessary.
    • Therapy for diversional, recreational, vocational purposes, or avocational purposes, for the remediation of learning disabilities, or for developmental activities which can be conducted by nonmedical personnel is non-covered.
    • One (1) hour of therapy must include a minimum of forty-five (45) minutes of direct care with the member. Only one (1) hour per day, per type of therapy may be approved.
    • Therapies which duplicate other services provided to a patient will not be authorized (e.g., nursing services).

Exceptions

    • Initial evaluations
    • Emergency respiratory therapy
    • Any combination of therapy services ordered in writing before a member’s release or discharge from an inpatient hospital, continuing for a period not to exceed thirty (30) units, sessions, or visits in thirty (30) calendar days
    • Deductible and copay or coinsurance for services covered by Medicare Part B
    • Oxygen equipment and supplies necessary for the delivery of oxygen, with the exception of concentrators
    • Therapy services provided by a nursing facility or large private or small intermediate care facility for individuals with intellectual disability (ICF/IID), which are included in the facility’s per diem rate
    • Respiratory therapy services ordered in writing for the acute medical diagnosis of asthma, pneumonia, bronchitis, or upper respiratory infection (not to exceed fourteen (14) hours or fourteen (14) calendar days without PA).
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