What Cigna requires for coverage
Cigna considers Physical Therapy medically necessary when the following criteria (from CPG 135) are met:
- A physical therapy evaluation is considered medically necessary for the assessment of a physical impairment.
- Physical therapy services are considered medically necessary to improve, adapt or restore functions which have been impaired or permanently lost and/or to reduce pain as a result of illness, injury, loss of a body part, or congenital abnormality when ALL of the following criteria are met:
- The individual's condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.
- The program is individualized, and there is documentation outlining quantifiable, attainable treatment goals.
- Improvement is evidenced by successive objective measurements.
- The services are delivered by a qualified provider of physical therapy services (i.e., appropriately trained and licensed by the state to perform physical therapy services).
- Physical therapy occurs when the judgment, knowledge, and skills of a qualified provider of physical therapy services are necessary to safely and effectively furnish a recognized therapy service due to the complexity and sophistication of the plan of care and the medical condition of the individual, with the goal of improvement of an impairment or functional limitation.
- Habilitative PT services are considered medically necessary when ALL criteria are met: therapy intended to keep, learn, or improve skills for daily living which have not developed or are at risk of being lost; services are evidence-based; expectation of improved function; written treatment plan with short/long-term goals; documentation objectively verifies functional status is kept or developed.
- Outpatient physical therapy treatment visit is limited to a maximum of 4 timed codes (equivalent to one hour) for each date of service.
- Massage therapy may be considered medically necessary when designed to restore muscle function, reduce edema, improve joint motion, or for relief of muscle spasm, and determined not duplicative to other modalities/procedures.
Covered procedure codes
How to appeal this denial
Frame your appeal around the specific criterion you satisfy. Quote the CPG 135 language above, then show — with your physician's records and clinical evidence — exactly how your situation meets it. Demand that Cigna 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: Cigna medical policy CPG 135 — view the published policy.