Medicare (CMS LCD/NCD) Outpatient Physical Therapy prior authorization requirements (2026)
What Medicare (CMS LCD/NCD) generally requires to approve Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035), for Medicare plans. Yes. Medicare (CMS LCD/NCD) generally requires prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035).
Medical-necessity criteria Medicare (CMS LCD/NCD) generally applies
Outpatient physical therapy is covered when it requires the skills of a qualified therapist and is reasonable and necessary for the patient's condition. Per the Jimmo v. Sebelius settlement, coverage of skilled therapy does NOT depend on the patient's potential for improvement — skilled care may be covered to improve the condition, to MAINTAIN the current condition, or to prevent or slow further deterioration. Document objective functional status, the specific skilled interventions, an individualized plan of care with measurable goals, and why the skills of a qualified therapist (versus an aide or caregiver) are required. For chronic neurological conditions such as spinal cord injury, skilled maintenance therapy to preserve function and prevent decline or complications is covered when skilled care is required.
Source
Source: CMS Jimmo v. Sebelius Settlement (cms.gov/medicare/settlements/jimmo); Medicare Benefit Policy Manual ch.15. Applies to outpatient therapy nationwide; the Improvement Standard is not a valid basis for denial. Medicare Advantage plans must apply this standard. Last verified 2026-06-10.
Frequently asked questions
Does Medicare (CMS LCD/NCD) require prior authorization for Outpatient Physical Therapy?
Yes. Medicare (CMS LCD/NCD) generally requires prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035).
What does Medicare (CMS LCD/NCD) require to approve Outpatient Physical Therapy?
Outpatient physical therapy is covered when it requires the skills of a qualified therapist and is reasonable and necessary for the patient's condition. Per the Jimmo v. Sebelius settlement, coverage of skilled therapy does NOT depend on the patient's potential for improvement — skilled care may be covered to improve the condition, to MAINTAIN the current condition, or to prevent or slow further d… Always confirm against the current Medicare (CMS LCD/NCD) policy.
How long does a Medicare (CMS LCD/NCD) prior authorization take?
Turnaround varies by plan and submission method. Check the Medicare (CMS LCD/NCD) portal for current timeframes.
Submitting Outpatient Physical Therapy to Medicare (CMS LCD/NCD)?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.