Aetna covers physical therapy that is expected to improve your function significantly, using the test in its Clinical Policy Bulletin 0325: measurable improvement within one month of starting, or setting up a safe home program. On Aetna HMO and similar plans, short-term therapy typically counts toward a 60-day treatment period or another rehab limit. Your plan document sets the cost share, and the therapist’s office confirms it before your first visit.
Last reviewed By the Monon Therapy Collective editorial team
- Aetna policy
- Clinical Policy Bulletin 0325, Physical Therapy
- Improvement test
- Significant progress within one month
- HMO-type plans
- Typically a 60-day treatment period
- Precertification
- Submitted by the provider when required
How does Aetna decide physical therapy is medically necessary?
Aetna asks whether therapy will significantly improve, develop or restore function lost to disease, injury or surgery. Its Clinical Policy Bulletin 0325 says your licensed practitioner must expect significant improvement, measured by things like active range of motion, strength, function or reported pain, within one month of the date therapy begins.
The second route to coverage is shorter: a few sessions to set up a safe, effective maintenance program you can carry out yourself. Either way, the services must follow a written plan of care with objective and subjective data. That is why your first visit spends so much time on measurements; the first visit guide explains what gets tested.
What is Aetna’s 60-day limit on physical therapy?
On Aetna HMO plans, the physical therapy benefit is typically limited to a 60-day treatment period. Aetna’s policy says short-term therapy in its HMO, QPOS, Health Network Only and Health Network Option plans accumulates toward that 60-day limit or another applicable rehabilitation limit.
The policy adds three details worth knowing. The 60-day treatment period applies to a specific condition, so a member can receive more than one 60-day course of therapy for separate conditions. Some plan designs apply the limit on a calendar-year or contract-year basis instead. Ask the therapist’s office how your plan counts the period, and read what happens if you run out of physical therapy visits if you are close to the end.
Other Aetna plans may set the limit differently, for example as a yearly visit count. Your Summary of Benefits and Coverage is the document that settles it.
When does Aetna stop paying for supervised sessions?
Aetna treats supervised therapy as no longer medically necessary once your goals are met or a home exercise program could do the same job. At that point care becomes maintenance, meaning it preserves function rather than restoring it, and Aetna does not cover it as rehabilitation.
This is a reasonable endpoint clinically, too. A therapist who knows the rule plans the last few weeks around making you independent, then hands you a written program. Many people move on to coached training once discharged, and FlexWerk’s independent coaches work next door to the therapy suites for that stage.
Does Aetna pay for physical therapy to get back to sport?
Partly. Aetna covers rehabilitation of an injury that limits normal daily function, but its policy excludes sports rehabilitation aimed at improving “above and beyond” the ability to perform activities of daily living, because that is not treatment of disease.
So a sprained ankle that makes stairs painful is rehab; the extra weeks of cutting and jumping drills before soccer season may not be. Some people pay directly for that last phase, or for return-to-sport testing. Ask the therapist’s office where your plan draws the line before you reach it.
Who handles Aetna precertification for physical therapy?
The provider does. Aetna asks providers to submit precertification electronically, through its provider website or by phone, for services on its precertification lists. Whether therapy needs it depends on your plan.
In the questionnaire, name Aetna and your plan type. The matching team proposes an independent therapist whose office works with Aetna where that is possible, and says so plainly if it is not. The therapist’s office then checks your benefits and any precertification before your first session in a private suite at Carmel City Center.
- Is my plan an HMO, QPOS, Health Network plan, or PPO?
- Does physical therapy count toward a 60-day period or a visit count?
- Is precertification required, and who submits it?
- What is my copay or coinsurance after the deductible?
