Arizona Complete HealthCommercial Clinical Policy

Physical Therapy Application - Ages 21+ Form

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Physical Therapy Application - Ages 21+

Indications

(1) Does the request meet this criterion: 15 visits per benefit year (10/01— 9/30) to restore a particular skill or function the individual previously had but lost due to injury or disease and maintain that function once restored; and,? 
(2) Does the request meet this criterion: 15 visits per benefit year (10/01— 9/30) to attain or acquire a particular skill or function never learned or acquired and maintain that function once acquired. Covered when medically necessary PHYSICAL THERAPY: INPATIENT? 
(3) Does the request meet this criterion: 15 visits per benefit year (10/01— 9/30) to attain or acquire a particular skill or function never learned or acquired and maintain that function once acquired.? 
(4) Does the request meet this criterion: 15 visits per benefit year (10/01— 9/30) to attain or acquire a particular skill or function never learned or acquired and maintain that function once acquired. SPEECH THERAPY: INPATIENT Covered when medically necessary Covered when medically necessary? 

Effective Date

NA

Last Reviewed

NA

Original Document

  Reference



AHCCCS MEDICAL POLICY MANUAL POLICY 310-X ATTACHMENT A AHCCCS ADULT MEMBER (PERSONS AGE 21 AND OLDER) THERAPY BENEFIT TABLE AHCCCS MEDICAL POLICY MANUAL POLICY 310-X ATTACHMENT A AHCCCS ADULT MEMBER (PERSONS AGE 21 AND OLDER) THERAPY BENEFIT TABLE – AHCCCS MEDICAL POLICY MANUAL POLICY 310-X ATTACHMENT A AHCCCS ADULT MEMBER (PERSONS AGE 21 AND OLDER) THERAPY BENEFIT TABLE

310-X, Attachment A – Page 1 of 1 Effective Date: 10/01/17 Revision Date: 11/16/17

ACUTE BENEFIT ALTCS BENEFIT OCCUPATIONAL THERAPY: INPATIENT Covered when medically necessary
Covered when medically necessary

OCCUPATIONAL THERAPY: OUTPATIENT • 15 visits per benefit year (10/01— 9/30) to restore a particular skill or function the individual previously had but lost due to injury or disease and maintain that function once restored; and, • 15 visits per benefit year (10/01— 9/30) to attain or acquire a particular skill or function never learned or acquired and maintain that function once acquired. Covered when medically necessary

PHYSICAL THERAPY: INPATIENT

Covered when medically necessary Covered when medically necessary

PHYSICAL THERAPY: OUTPATIENT • 15 visits per benefit year (10/01— 9/30) to restore a particular skill or function the individual previously had but lost due to injury or disease and maintain that function once restored; and, • 15 visits per benefit year (10/01— 9/30) to attain or acquire a particular skill or function never learned or acquired and maintain that function once acquired.
• 15 visits per benefit year (10/01— 9/30) to restore a particular skill or function the individual previously had but lost due to injury or disease and maintain that function once restored; and, • 15 visits per benefit year (10/01— 9/30) to attain or acquire a particular skill or function never learned or acquired and maintain that function once acquired. SPEECH THERAPY: INPATIENT Covered when medically necessary

Covered when medically necessary
SPEECH THERAPY: OUTPATIENT

Not a covered benefit

Covered when medically necessary

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