Work Hardening Programs — CPB 0198 | AETNA Coverage Update

Aetna modified CPB 0198 for work hardening programs, effective September 26, 2025. CPT codes 97545, 97546, and 97537—along with HCPCS S9117—are not covered for the indications listed in this bulletin. Here's what billing teams need to know.

Aetna updated Clinical Policy Bulletin 0198 governing work hardening and work conditioning programs. This coverage policy change affects occupational therapy, physical therapy, and rehabilitation billing teams who submit claims for CPT 97545 (work hardening/conditioning, initial two hours), CPT 97546 (each additional hour), CPT 97537 (community/work reintegration training), and HCPCS S9117 (back school, per visit). The policy update took effect September 26, 2025.

Quick-Reference Table

Aetna Work Hardening Program Coverage Criteria and Medical Necessity Requirements 2025

The core issue with CPB 0198 is straightforward: Aetna's coverage policy places CPT 97545, CPT 97546, CPT 97537, and HCPCS S9117 in the "not covered" bucket for the indications described in this bulletin. There are no covered tiers listed and no medical necessity criteria that unlock reimbursement for these services under this policy.

That's an unusual structure. Most payer policies include some covered indications alongside exclusions. This one does not. The entire code set sits in the non-covered column.

If your team has been submitting CPT 97545 or 97546 expecting coverage under Aetna plans, the September 26, 2025 effective date means you need to audit what's in your billing queue now.

The ICD-10-CM codes attached to this policy span a wide range—injuries and poisonings (S00.00X+ through T88.9XX+), post-surgical histories (Z98.870–Z98.891), and encounter codes for aftercare and rehabilitation (Z51.89). The breadth of those diagnosis codes tells you something: Aetna is signaling that work hardening won't be covered regardless of the underlying condition driving the referral. A post-surgical patient, an injury recovery case, a worker returning from a musculoskeletal event—none of these automatically open a coverage door under CPB 0198.

Aetna Work Hardening Program Exclusions and Non-Covered Indications

The Aetna work hardening coverage policy under CPB 0198 does not divide services into covered and non-covered tiers. The entire applicable code set is non-covered for the indications listed in the bulletin.

CPT 97545 and CPT 97546 — Work hardening and conditioning programs. Aetna does not cover the initial two-hour session or any additional hours billed under this code pair for the listed indications.

CPT 97537 — Community and work reintegration training, which includes activities like shopping, transportation, money management, and vocational tasks. This is also not covered.

HCPCS S9117 — Back school, per visit. Also excluded.

The ICD-10-CM diagnosis codes attached to this policy cover a broad span of post-injury, post-surgical, and rehabilitation-related conditions. Work hardening programs are almost exclusively prescribed for exactly these patient populations—people recovering from occupational injuries, post-surgical patients returning to physically demanding jobs, and individuals with musculoskeletal conditions managed through a functional restoration approach. Aetna's non-coverage position applies directly to the patients most likely to be referred to these programs.

Coverage Indications at a Glance

Aetna Work Hardening Program Billing Guidelines and Action Items 2025

This policy has a hard effective date of September 26, 2025. If that date has already passed, you are in the enforcement window. Act on these items now.

Note: Items 2–4 above reflect general billing best practices and are not derived from CPB 0198 source data.

CPT, HCPCS, and ICD-10 Codes for Work Hardening Programs Under CPB 0198

Not Covered CPT Codes Under CPB 0198

Not Covered HCPCS Codes Under CPB 0198

ICD-10-CM Diagnosis Codes Referenced in CPB 0198

The volume of Z98 codes here is worth noting. Aetna mapped out nearly two dozen distinct post-surgical history codes in this policy. That's not an accident. It closes off the argument that work hardening is covered when the underlying cause is surgical rather than injury-based. The diagnosis range combined with the injury codes (S00–T88) leaves very little clinical territory outside the non-coverage designation.