Aetna modified CPB 0325 for physical therapy services, effective October 31, 2025. Here's what billing teams need to know before claims start hitting the new criteria.
Aetna, a CVS Health company, updated its physical therapy coverage policy under CPB 0325 in the Aetna clinical policy bulletin system. The revised policy affects a broad set of PT codes—including CPT 97110, 97112, 97140, 97161–97164, and 97530, plus home-based HCPCS codes G0151, G0159, and S9131. If your practice bills physical therapy services to Aetna members, the medical necessity criteria in this update directly affect your claim approval rate and reimbursement.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Physical Therapy Services |
| Policy Code | CPB 0325 |
| Change Type | Modified |
| Effective Date | October 31, 2025 |
| Impact Level | High |
| Specialties Affected | Physical Therapy, Orthopedics, Sports Medicine, Neurology, Home Health |
| Key Action | Audit your PT plan-of-care documentation against CPB 0325 criteria before billing claims with dates of service on or after October 31, 2025 |
Aetna Physical Therapy Coverage Criteria and Medical Necessity Requirements 2025
The Aetna physical therapy coverage policy under CPB 0325 sets five conditions that must all be met for PT to be considered medically necessary. Miss any one of them and you're looking at a claim denial.
Condition 1: Measurable improvement within one month. The member's licensed health care practitioner must determine that the condition can improve significantly—based on objective physical measures like active range of motion (AROM), strength, functional scores, or pain level—within one month of therapy starting. Alternatively, the services must be necessary to establish a safe and effective maintenance program that the member will perform independently after skilled therapy ends.
Condition 2: Reasonable expectation of significant improvement. PT is covered only for episodes where a reasonable expectation exists that the member's condition will improve significantly in a predictable period. Ongoing, indefinite therapy without defined functional goals does not meet this threshold.
Condition 3: Licensed provider requirement. All PT services must be performed by a duly licensed and certified PT provider. Services must fall within the applicable scope of practice in the jurisdiction where care is delivered. This is a hard credential check—providers outside their licensed scope create automatic denial exposure.
Condition 4: Complexity requiring skilled care. The services must be complex enough to require a licensed professional therapist or qualified supervision of a licensed ancillary person under state law. Physicians may supervise personnel under their direct supervision as permitted by state law, but they cannot directly supervise physical therapy assistants—they are not licensed as physical therapists.
Condition 5: Written plan of care with documented medical necessity. PT must follow an ongoing, written plan of care. The plan must include sufficient objective and subjective data to demonstrate medical necessity for the proposed treatment. Thin documentation is the most common reason these claims get flagged. See the Appendix section of CPB 0325 for Aetna's specific documentation requirements.
Home-based PT (billed under G0151, G0159, or S9131) is covered in selected cases. Aetna considers it medically necessary when the home environment is relevant to the member's functional performance or when it's part of a transition from skilled therapy to a maintenance program. For members on HMO, QPOS, Health Network Only, or Health Network Option plans, short-term home-based PT counts toward the 60-day limit or other applicable rehabilitation benefit limits. Check the member's benefit plan before submitting.
Prior authorization requirements are not explicitly detailed within the CPB 0325 criteria summary, but Aetna's authorization policies vary by plan type. Confirm prior auth requirements at the plan level before scheduling PT beyond initial evaluations.
Aetna Physical Therapy Exclusions and Non-Covered Indications
This is where the Aetna physical therapy coverage policy gets specific—and where billing teams tend to trip up.
Four PT methods lack sufficient evidence to justify out-of-network referrals. Aetna explicitly states there are no reliable data showing these methods produce superior outcomes compared to standard PT:
| # | Excluded Procedure |
|---|---|
| 1 | McKenzie Method of Mechanical Diagnosis and Therapy |
| 2 | Muldowney Method of Physical Therapy |
| 3 | Muscle Activation Techniques (MAT) |
| 4 | Postural Restoration Form of Physical Therapy |
The real issue here is what Aetna does with this finding. When a standard in-network PT option is available, Aetna considers it not medically necessary to go out of network specifically for these methods. If a member insists on out-of-network MAT or Muldowney Method PT, and an in-network standard PT provider is available, the claim for out-of-network services will not be covered on medical necessity grounds. Train your authorization staff to flag these requests before scheduling.
Three absolute non-coverage conditions apply across all PT codes:
| # | Excluded Procedure |
|---|---|
| 1 | PT for asymptomatic persons or persons without an identifiable clinical condition—not covered. |
| 2 | PT for members whose condition is neither improving nor declining—not covered. |
| 3 | Continuing supervised PT once therapeutic benefit has been achieved, or when a home exercise program would produce further gains—not covered. |
The third point is where the most revenue risk lives. Aetna is drawing a clear line: once a patient plateaus at a functional level that a home program can maintain or advance, supervised PT reimbursement stops. Document the clinical rationale for every continued session explicitly. If your notes say "patient tolerating exercises well" without documenting continued skilled need, expect a denial.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| PT to restore/improve physical function lost due to disease, injury, or surgery | Covered | 97110, 97112, 97116, 97140, 97161–97164, 97530 | All five medical necessity criteria must be met |
| PT for maintenance program establishment | Covered | 97535, 97537 | Must show skilled need to set up program; member performs independently after |
| Home-based PT for functional needs in home environment | Covered | G0151, G0159, S9131 | Counts toward 60-day limit in HMO/QPOS/HNO/HNO plans |
| PT for asymptomatic persons | Not Covered | All PT codes | No identifiable clinical condition |
| PT when condition is neither improving nor declining | Not Covered | All PT codes | Documented plateau without skilled need = denial |
| Continuing supervised PT once therapeutic benefit achieved | Not Covered | All PT codes | Transition to home exercise program instead |
| Out-of-network McKenzie Method (in-network standard PT available) | Not Covered | All PT codes | No superior outcomes data; in-network alternative must be unavailable |
| Out-of-network Muldowney Method PT (in-network standard PT available) | Not Covered | All PT codes | Same rationale as McKenzie |
| Out-of-network Muscle Activation Techniques (in-network standard PT available) | Not Covered | All PT codes | Same rationale |
| Out-of-network Postural Restoration PT (in-network standard PT available) | Not Covered | All PT codes | Same rationale |
| Aquatic therapy with therapeutic exercise | Covered when criteria met | 97113 | Must meet all five criteria |
| Group therapeutic procedures | Covered when criteria met | 97150 | Must meet complexity and skilled-need threshold |
| Motor-cognitive virtual reality gait training | Covered when criteria met | +0791T | Add-on code; primary procedure required |
Aetna Physical Therapy Billing Guidelines and Action Items 2025
CPB 0325 is a high-volume policy. These action items apply to every PT claim your team submits to Aetna with dates of service on or after October 31, 2025.
| # | Action Item |
|---|---|
| 1 | Audit your plan-of-care documentation against all five medical necessity criteria before October 31, 2025. Every active Aetna PT patient needs a chart review. The plan of care must include objective data (AROM, strength, functional scores, pain levels) and a clearly documented expectation of significant improvement within one month. Templates that don't capture this data specifically are a liability now. |
| 2 | Flag the four excluded PT methods in your scheduling and authorization workflow. If your practice offers McKenzie, Muldowney, MAT, or Postural Restoration PT, and an Aetna member has in-network standard PT options available, document that the member was informed of coverage limitations before their first visit. Verbal warnings after a denial don't help your revenue. |
| 3 | Update your physical therapy billing charge capture to require discharge planning documentation at defined milestones. Aetna's coverage policy terminates when therapeutic benefit is achieved or a home exercise program suffices. Build a checkpoint at four to six weeks—before benefit thresholds—to document continued skilled need explicitly. If your notes don't show why a home program isn't yet appropriate, the claim is vulnerable. |
| 4 | Verify home-based PT benefit limits at the plan level before scheduling. G0151, G0159, and S9131 are covered for home PT, but HMO, QPOS, Health Network Only, and Health Network Option members have a 60-day limit or plan-specific rehabilitation cap. Check the member's benefit before the first home visit, not after you've already accumulated sessions. |
| 5 | Confirm prior authorization status for extended PT episodes. CPB 0325 doesn't specify prior auth triggers in the summary, but Aetna plan types vary. For any Aetna member approaching more than four to six visits, verify whether continuing PT requires authorization. A retroactive denial on week eight hurts significantly more than a pre-authorization call on week two. |
| 6 | Train your physical therapy assistants and supervising physicians on scope limitations. Physicians cannot directly supervise physical therapy assistants under CPB 0325. If your billing includes physician-supervised PTA services, review those arrangements with your compliance officer before the effective date of October 31, 2025. |
| 7 | Review any unlisted code usage (97039, 97139). Aetna groups these under "other CPT codes related to the CPB." Unlisted codes require detailed documentation of the specific service. If your team uses these codes routinely, confirm your documentation will support medical necessity review under the updated criteria. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Physical Therapy Under CPB 0325
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 97010 | CPT | Application of modality; hot or cold packs |
| 97012 | CPT | Traction, mechanical |
| 97014 | CPT | Electrical stimulation (unattended) |
| 97016 | CPT | Vasopneumatic devices |
| 97018 | CPT | Paraffin bath |
| 97022 | CPT | Whirlpool |
| 97024 | CPT | Diathermy (e.g., microwave) |
| 97026 | CPT | Infrared |
| 97028 | CPT | Ultraviolet |
| 97032 | CPT | Electrical stimulation (manual), each 15 minutes |
| 97033 | CPT | Iontophoresis, each 15 minutes |
| 97034 | CPT | Contrast baths, each 15 minutes |
| 97035 | CPT | Ultrasound, each 15 minutes |
| 97036 | CPT | Hubbard tank, each 15 minutes |
| 97110 | CPT | Therapeutic exercises to develop strength, each 15 minutes |
| 97112 | CPT | Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception |
| 97113 | CPT | Aquatic therapy with therapeutic exercise |
| 97116 | CPT | Gait training (includes stair climbing) |
| 97124 | CPT | Massage, including effleurage, petrissage and/or tapotement |
| 97129 | CPT | Therapeutic interventions focused on cognitive function, initial 15 minutes |
| +97130 | CPT | Therapeutic interventions focused on cognitive function, each additional 15 minutes (add-on) |
| 97140 | CPT | Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction) |
| 97161 | CPT | Physical therapy evaluation, low complexity |
| 97162 | CPT | Physical therapy evaluation, moderate complexity |
| 97163 | CPT | Physical therapy evaluation, high complexity |
| 97164 | CPT | Physical therapy reevaluation |
| 97530 | CPT | Therapeutic activities, direct one-on-one patient contact |
| 97535 | CPT | Self-care/home management training (ADL and compensatory training) |
| 97537 | CPT | Community/work reintegration training |
| 97542 | CPT | Wheelchair management (assessment, fitting, training), each 15 minutes |
| 97760 | CPT | Orthotic(s) management and training, each 15 minutes |
| 97761 | CPT | Prosthetic training, upper and/or lower extremity, each 15 minutes |
| 97763 | CPT | Orthotic(s)/prosthetic(s) management and/or training, each 15 minutes |
| 99509 | CPT | Home visit for assistance with activities of daily living and personal care |
| +0791T | CPT | Motor-cognitive, semi-immersive virtual reality–facilitated gait training, each 15 minutes (add-on) |
Other CPT Codes Related to CPB 0325
| Code | Type | Description |
|---|---|---|
| 97039 | CPT | Unlisted modality (specify type and time if constant attendance) |
| 97139 | CPT | Unlisted therapeutic procedure (specify) |
| 97150 | CPT | Therapeutic procedure(s), group (2 or more individuals) |
Covered HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| G0151 | HCPCS | Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes |
| G0159 | HCPCS | Services performed by a qualified physical therapist in the home health setting, in the establishment or delivery of a safe and effective maintenance program, each 15 minutes |
| S9131 | HCPCS | Physical therapy; in the home, per diem |
Other HCPCS Codes Related to CPB 0325
| Code | Type | Description |
|---|---|---|
| A4450 | HCPCS | Tape, non-waterproof, per 18 square inches |
| A4452 | HCPCS | Tape, waterproof, per 18 square inches |
| G0152 | HCPCS | Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes |
| G0153 | HCPCS | Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes |
| G0157 | HCPCS | Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes |
| G2168 | HCPCS | Services performed by a physical therapist assistant in the home health setting in the delivery of a safe and effective maintenance program, each 15 minutes |
| S9128 | HCPCS | Speech therapy, in the home, per diem |
| S9129 | HCPCS | Occupational therapy, in the home, per diem |
No ICD-10-CM codes are specified in CPB 0325's policy data.
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