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. Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require 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). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
Medical-necessity criteria Medicare (CMS LCD/NCD) generally applies
No prior authorization exists for outpatient PT under original Medicare Part B - coverage turns on medical necessity for skilled care (the skills of a qualified therapist, reasonable and necessary for the condition), documented under a certified plan of care. Payment mechanics instead of PA: for CY 2026 the KX-modifier threshold is $2,480 for PT and speech-language pathology COMBINED (separate $2,480 for OT) - claims above the threshold without the KX modifier are DENIED; appending KX attests medical necessity is documented in the record. A targeted medical review threshold of $3,000 (PT+SLP combined) applies through CY 2028; claims above it may be selected for review based on billing patterns.
Commonly required documentation
- Certified plan of care (physician/NPP signature), evaluation with objective/standardized measures, treatment notes supporting skilled therapy, KX modifier on claims once the annual threshold is exceeded, GP therapy modifier.
How to submit
- Method: Standard claim submission to the Medicare Administrative Contractor; KX modifier when over threshold
Sources & verification
Source: CMS Transmittal 13437 / CR 14252 (Pub 100-04, Oct 30 2025, eff. Jan 1 2026) - 2026 thresholds read directly from the transmittal. Corrected 2026-07-09: previous row said PA required; original Medicare has NO PA for outpatient PT. [NEEDS CLINICAL SPOT-CHECK] View the source policy. Last verified 2026-07-09.
Frequently asked questions
Does Medicare (CMS LCD/NCD) require prior authorization for Outpatient Physical Therapy?
Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require 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). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
What does Medicare (CMS LCD/NCD) require to approve Outpatient Physical Therapy?
No prior authorization exists for outpatient PT under original Medicare Part B - coverage turns on medical necessity for skilled care (the skills of a qualified therapist, reasonable and necessary for the condition), documented under a certified plan of care. Payment mechanics instead of PA: for CY 2026 the KX-modifier threshold is $2,480 for PT and speech-language pathology COMBINED (separate $2,… 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.