CPT 97761, in plain terms, covers First encounter for training in use of an arm or leg prosthesis, reported per 15 minutes. CPT 97761 is referenced in 6 tracked payer policy changes from Sentara Health Plans, CareSource, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 97761 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 97761 on AAPC
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
CareSource Georgia Medicaid is adding prior authorization requirements for skin substitutes, outpatient therapy codes, new Q1 2025 codes, and other outpatient services effective July 10, 2025. This affects a wide range of commonly used therapy and treatment codes that will require pre-approval before services can be rendered.
Effective June 1, 2026, Blue Shield of California updated the physical therapy policy statement, guidelines and literature. Rehabilitative PT is medically necessary when a qualified physical therapist is needed, the condition has the potential to improve in a reasonable and predictable period of time, and the documentation objectively verifies progressive functional improvement with quantifiable and attainable goals. Once a maintenance program is designed, coverage is not medically necessary when the patient can generally perform it alone or with family, a caregiver, or unskilled personnel, and evaluation and management codes 99201 through 99499 are not separately billable by physical therapists in independent practice.
This new policy was created on 11/20/25 from the content merger of policies 8.01.13, 8.01.12 and 8.01.17. Initial physical, occupational or speech therapy is considered medically appropriate with a qualifying indication determined by standardized assessments, and continuation requires significant improvement in objective measures, continued improvement within the past treatment period, an updated treatment plan and active participation in therapy. Non-skilled services, maintenance programs, sensory integration therapy, hippotherapy, gait analysis, isokinetic testing and work-related programs are considered not medically necessary, while dry needling and constraint-induced movement therapy used as a sole measure are considered investigational.
Aetna's Clinical Policy Bulletin 0325 sets the medical necessity rules for physical therapy. PT is considered medically necessary when the licensed practitioner determines the condition can improve significantly within one month or the services are needed to set up a safe maintenance program, the services treat a specific illness or injury, and the care follows an ongoing written plan of care. Supervised PT is not medically necessary once therapeutic benefit has been achieved, sports rehabilitation is not covered, and listed methods such as Kinesio taping are considered experimental, investigational, or unproven.
BCBSAZ covers telehealth only as the member's benefit plan provides. Under the BlueCare Anywhere benefit, telehealth is covered when the Telehealth Services Administrator provides the service and determines the condition is appropriate, for a medical, therapy or psychiatry consultation. Under the in-network telehealth benefit, a service is covered when it would be covered in person and can be provided effectively by telehealth, through audio-visual services or limited audio-only services, and out-of-network non-emergency telehealth is not covered. The most recent review, dated 07/29/26, made no revisions.
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