Outpatient Rehabilitation & Maintenance Therapy • Medical Necessity & Prior Authorization

PT, OT & Speech Therapy (LSVT BIG, LSVT LOUD & Swallow Studies) — Medical Necessity Checklist

Billing & Coverage Codes: CPT 97161–97163, 97110, 97112, 97116 (Physical Therapy / LSVT BIG) • CPT 97165–97167, 97535 (Occupational Therapy) • CPT 92523, 92507 (Speech Therapy / LSVT LOUD) • CPT 92611 + 74230 (Swallow Study)

Important Policy Notice — Not a Guarantee of Approval: Clinical coverage criteria change periodically and your health plan's official Evidence of Coverage and clinical policy determination are final. This checklist summarizes published CMS and commercial payer policies for educational preparation and is never a guarantee of approval.

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Plain-English Clinical Documentation Checklist

What Your Neurologist / Care Team Must Document in the Chart Note

A standard LSVT BIG or LSVT LOUD course requires 16 one-hour 1-on-1 sessions (4 days/week for 4 weeks). Furthermore, under the federal Jimmo v. Sebelius settlement, Medicare CANNOT deny therapy simply because Parkinson's is progressive and the goal is to maintain function or slow decline rather than 'cure' the patient. Document these 5 items:

1Signed Plan of Care (POC) certified by the referring neurologist or primary care physician within 30 days of the initial evaluation, recertified at least every 90 days.

2Objective functional baseline deficits specific to Parkinson's (e.g., Timed Up and Go [TUG] > 12 seconds, Berg Balance Scale score, freezing of gait episodes/falls, vocal intensity reduction in dB SPL for hypophonia, or micrographic handwriting/ADL impairment).

3Why the complexity of the patient's Parkinson's condition requires the skilled judgment of a licensed therapist (rather than an unskilled home exercise program or caregiver-assisted walk).

4For Maintenance Therapy (Jimmo v. Sebelius standard): explicit documentation that skilled therapy is required to prevent or slow further deterioration in safety, gait, or swallowing, or that unskilled personnel cannot safely carry out the program.

5Once annual Medicare Part B therapy charges exceed the CY 2026 $2,480 threshold (combined for PT + Speech, and a separate $2,480 for OT): the clinic must append the 'KX' modifier to every claim attesting that continued therapy is medically necessary.

Published Clinical Policy Citations

CMS Medicare & Major Commercial Payer Policies

Medicare (Original Medicare & Jimmo v. Sebelius Settlement)Verified Oct 2026

CMS Medicare Benefit Policy Manual (MBPM) Chapter 15, §§ 220–230 & Jimmo v. Sebelius Maintenance Standard

Skilled therapy is covered when needed to maintain the patient's current condition or prevent/slow further deterioration, even when full restoration is not expected. Claims above the $2,480 CY 2026 threshold require the KX modifier; targeted medical review begins at $3,000.

View Official Source Policy (https://www.cms.gov/medicare/settlements/jimmo-settlement)

Anthem Blue Cross / Blue Shield / UHC / Aetna / Cigna (Commercial Plans)Verified Oct 2026

Commercial Outpatient Rehabilitative & Habilitative Therapy Clinical Guidelines

Covers medically necessary PT, OT, and Speech therapy for neurological impairments (gait instability, dysphagia, hypophonia). Watch for employer ERISA plan hard visit caps (20–60 visits/year); state-regulated CA plans must cover medically necessary rehabilitative services under Essential Health Benefits.

View Official Source Policy (https://www.dmhc.ca.gov/)

Other Parkinson's Medical Necessity Checklists

DBS Surgery (CPT 61885 / 61867)DaTscan SPECT (CPT 78803 + A9584)Home Health Care (CPT 99349 / G0151 / G0153)Duopa (J7340) & Vyalev Infusion Pumps Brand Parkinson's Drugs Prior Auth