1. Aetna considers short-term occupational therapy medically necessary in selected cases when this care is prescribed by a physician, and either of the following criteria applies:

   • To provide task-oriented therapeutic activities designed to significantly improve, develop or restore physical functions lost or impaired as a result of a disease, or injury; or

   • To learn or relearn daily living skills (e.g., dressing, eating and bathing) or compensatory techniques to improve the level of independence in the activities of daily living.

   Occupational therapy services are considered medically necessary only if there is a reasonable expectation that occupational therapy will achieve measurable improvement in the member's condition in a reasonable and predictable period of time.

   Notes:

   • Driver training is not considered treatment of disease because driving an automobile is not a basic activity of daily living.
   • In addition to use in non-chronic conditions and acute illnesses, a role for occupational therapy has been proposed in the management of certain chronic diseases.  It may be used to slow or prevent further deterioration of body function impaired by a neurological disease such as multiple sclerosis, cerebral palsy, polio, spina bifida and amyotrophic lateral sclerosis (Lou Gehrig's disease).  Most Aetna policies limit coverage of occupational therapy to non-chronic conditions and acute illnesses.
   • Occupational therapy may require precertification in some plan designs.  Subject to plan benefit descriptions, coverage of occupational therapy may be limited. In many of our HMO plans the benefit is limited to a 60 day treatment period.  In these plans, the treatment period of 60 days applies to a specific condition.  Once the 60-day treatment period expires, no additional occupational therapy benefits will be provided for that condition during the contract year. However, it is possible for a member to receive more than one 60-day treatment course of occupational therapy per year as treatment of separate conditions.  For example, a surgical procedure causing the need for occupational therapy is considered to be the initiation of a new or separate condition in a person who previously received occupational therapy for another indication, and so qualifies the member to receive coverage for an additional course of occupational therapy as outlined above.  An exacerbation or flare-up of a chronic illness is not considered to be a new incident of illness.
   • Other HMO and PPO and Indemnity plans have different benefits for occupational therapy. In some cases the benefits are defined by a total number of sessions covered per year. In other benefit designs, occupational therapy may be covered as an unlimited benefit as long as it is documented that the members is progressing towards a goal.  Consult the specific certificates of coverage for details of plan benefits.

   • Aetna policies typically exclude coverage for services, treatment, education testing, or training related to learning disabilities or developmental delays. When the policy has such an exclusion, occupational therapy is not covered when the primary or the only diagnosis for a member is mental retardation or a learning disability such as a perceptual handicap, brain damage not caused by accidental injury or illness, minimal brain dysfunction, dyslexia, or developmental delay.

2. Aetna considers home-based occupational therapy medically necessary in selected cases based upon the member's needs.  This is usually used in the transition of the member from hospital to home and is an extension of case management services.

   Note: In Aetna’s HMO and QPOS plans, such home based occupational therapy accumulates towards the 60-day limit or other applicable rehabilitation benefit limits.  Please check benefit plan descriptions for details.

Occupational therapy is a health care service that involves the use of purposeful activities to help people regain performance skills lost through injury or illness.  Individual programs are designed to improve quality of life by recovering competence, maximizing independence, and prevent injury or disability as much as possible, so that a person can cope with work, home, and social life.

Appendix

Documentation Requirements:

The following care plan is required to document the medical necessity of occupational therapy:

1. Occupational therapy must be provided in accordance with an ongoing, written plan of care. The purpose of the written plan of care is to assist in determining medical necessity.
2. The plan of care must include sufficient information to determine the medical necessity of treatment. The plan of care must be specific to the diagnosis, presenting symptoms, and findings of the occupational therapy evaluation.
3. The plan of care must be signed by the member's attending physician and occupational therapist.
4. The plan of care should include:
   1. The date of onset or exacerbation of the disorder/diagnosis;
   2. Specific statements of long-term and short-term goals;
   3. Quantitative objectives;
   4. A reasonable estimate of when the goals will be reached;
   5. The specific treatment techniques and/or exercises to be used in treatment; and
   6. The frequency and duration of treatment.

The plan of care should be ongoing (i.e., updated as the member's condition changes) and treatment should demonstrate reasonable expectation of improvement (as defined below):

The member should be re-evaluated regularly, and there should be documentation of progress made toward the goals of occupational therapy.

The treatment goals and subsequent documentation of treatment results should specifically demonstrate that occupational therapy services are contributing to such improvement.