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Excellus BlueCross BlueShieldCommercial · Coverage · Therapy & Rehabilitation · NY · Physical Therapy, Occupational Therapy, Speech TherapyMedium impact

Therapies (Speech, Physical and Occupational) 8.01.24

Effective date
Nov 20, 2025
Identified
Jun 20, 2026

Summary

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.

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What to do

Action · 5 steps
01Already effective 2025-11-20: Billing team: Before billing therapy, confirm the documentation includes a written plan of care with the diagnosis and severity level, long- and short-term functional goals, measurable objectives, a reasonable estimate of when goals will be reached, the specific treatment techniques, the frequency and duration of treatment, and the prior, prior-treatment and current level of function.
02Continuation claims need documentation of continued improvement within the past treatment period, an updated treatment plan and evidence that the member is actively participating in therapy sessions.
03Outpatient therapy requested for a child who already receives school-based services in an IEP needs documentation of the rationale for medical necessity beyond what the child receives at school.
04Coverage is not available for services provided by school districts under an IEP.
05Check the 97533 and 97537 codes and the other non-skilled and maintenance services in charge entry, since the policy considers them not medically necessary.

Codes mentioned

2056020561925079250892521925229252392524925269261096105970109701297014970169701897022970249702697028970329703397034970359703697110971129711397116971409715097161971629716397164971689753097533975359753797542975459754697750977609776197763S9128S9152G0129

Original notice

Therapies (Speech, Physical and Occupational) 8.01.24
excellusbcbs.com · Always check the source before changing claims.
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Related policy hubs

Excellus BlueCross BlueShield policiesNY policy changesPhysical TherapyOccupational TherapySpeech TherapyCode 20560Code 20561Code 92507Code 92508Code 92521Code 92522Code 92523Code 92524Code 92526Code 92610Code 96105Code 97010Code 97012Code 97014Code 97016Code 97018Code 97022Code 97024Code 97026Code 97028Code 97032Code 97033Code 97034Code 97035Code 97036Code 97110Code 97112Code 97113Code 97116Code 97140Code 97150Code 97161Code 97162Code 97163Code 97164Code 97168Code 97530Code 97533Code 97535Code 97537Code 97542Code 97545Code 97546Code 97750Code 97760Code 97761Code 97763Code S9128Code S9152Code G0129

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