What Aetna requires for coverage
Aetna considers Physical Therapy medically necessary when the following criteria (from CPB 0325) are met:
- Aetna considers physical therapy (PT) medically necessary to significantly improve, develop or restore physical functions lost or impaired as a result of a disease, injury or surgical procedure, and the following criteria are met:
- 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 therapy services proposed must be necessary for the establishment of a safe and effective maintenance program that will be performed by the member without ongoing skilled therapy services. These services must be proposed for the treatment of a specific illness or injury.
- The PT services provided are intended to cover only episodes of therapy for situations where there must be a reasonable expectation that a member's condition will improve significantly in a reasonable and generally predictable period of time.
- PT services must be performed by a duly licensed and certified, if applicable, PT provider. All services provided must be within the applicable scope of practice for the provider in their licensed jurisdiction where the services are provided.
- The services provided must be of the complexity and nature to require that they are performed by a licensed professional therapist or provided under the supervision by a licensed ancillary person as permitted under state laws.
- PT must be provided in accordance with an ongoing, written plan of care. The PT plan of care should be of such sufficient detail and include appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment.
- Home-based physical therapy is considered medically necessary in selected cases based upon the member's needs, in order 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.
Covered procedure codes
| 97010 | Application of a modality to 1 or more areas; hot or cold packs |
| 97012 | Traction, mechanical |
| 97014 | Electrical stimulation (unattended) |
| 97016 | Vasopneumatic devices |
| 97018 | Paraffin bath |
| 97022 | Whirlpool |
| 97024 | Diathermy (eg, microwave) |
| 97026 | Infrared |
| 97028 | Ultraviolet |
| 97032 | Electrical stimulation (manual), each 15 minutes |
| 97033 | Iontophoresis, each 15 minutes |
| 97034 | Contrast baths, each 15 minutes |
How to appeal this denial
Frame your appeal around the specific criterion you satisfy. Quote the CPB 0325 language above, then show — with your physician's records and clinical evidence — exactly how your situation meets it. Demand that Aetna either approve the claim or identify the precise criterion they believe you fail. CareCost Appeals assembles this automatically: it cites the policy, pulls verified clinical evidence, and applies your state and federal appeal rights.
Source: Aetna medical policy CPB 0325 — view the published policy.