Cigna Healthcare modified CPG 135 (cpg135_physical_therapy) for physical therapy services, effective December 16, 2025. Here's what changes for billing teams.
Cigna Healthcare updated its physical therapy coverage policy under CPG 135, tightening the definition of skilled therapy services and reinforcing the progression requirements that determine ongoing medical necessity. The policy directly affects 46 CPT codes and nine HCPCS codes — including high-volume codes like 97110, 97140, 97161–97164, 97530, and 97535. If your practice bills PT services to Cigna members, audit your documentation protocols now, before claims start hitting the December 16, 2025 effective date.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Cigna Healthcare |
| Policy | Physical Therapy (CPG 135) |
| Policy Code | cpg135_physical_therapy |
| Change Type | Modified |
| Effective Date | December 16, 2025 |
| Impact Level | High |
| Specialties Affected | Physical therapy, outpatient rehabilitation, home health, hospice, occupational therapy (where PT overlap exists) |
| Key Action | Review documentation for skilled service justification and functional progression before submitting PT claims under CPG 135 on or after December 16, 2025 |
Cigna Physical Therapy Coverage Criteria and Medical Necessity Requirements 2025
The core question Cigna asks on every PT claim is simple: does this service require a licensed therapist to perform or supervise it? If the answer is no, the service is not medically necessary — full stop. It doesn't matter that a therapist actually delivered the service.
This is the sharpest edge of the CPG 135 coverage policy. Cigna explicitly states that a service doesn't become skilled just because a therapist performs it. If the treatment can be safely and effectively delivered through a home exercise program, a self-management program, a restorative nursing program, or a caregiver-assisted program, Cigna considers physical therapy services not indicated and not medically necessary. That's a direct documentation challenge for high-volume codes like 97110 (therapeutic exercise), 97112 (neuromuscular reeducation), and 97530 (therapeutic activities).
Rehabilitative vs. Habilitative Services
Cigna's CPG 135 draws a clear line between rehabilitative and habilitative PT.
Rehabilitative PT targets functions that were impaired or lost due to illness, injury, loss of a body part, or congenital abnormality. The goal must be achievable in a reasonable period of time. Cigna sets explicit progression thresholds: no improvement after two weeks means you should attempt an alternative treatment plan. No significant improvement after four weeks may require re-evaluation by the referring provider. Once a patient stops progressing toward established goals, treatment is no longer medically necessary. This directly affects billing for ongoing courses of treatment — if you're billing 97110 or 97140 week after week without documented progress, Cigna will deny those claims.
Habilitative PT covers services that help a patient keep, learn, or improve skills for daily living — specifically activities of daily living (ADLs) or instrumental activities of daily living (IADLs) that haven't developed normally or are at risk of being lost. A child not walking at the expected developmental age is the example Cigna cites directly. These services support codes like 97535 (self-care/home management training) and 97542 (wheelchair management).
Skilled Service Requirement
This is where physical therapy billing teams get tripped up. The unavailability of an unskilled caregiver does not make a non-skilled service suddenly skilled. Cigna is explicit: importance to the patient is not the test. The test is whether the service requires professional skills to perform or supervise. If your documentation can't answer that question clearly, expect a claim denial.
Document the clinical complexity. Document why a home program isn't sufficient. Document what the therapist is doing that an unskilled person cannot safely replicate. That documentation is your defense in a Cigna audit.
Prior Authorization
CPG 135 does not specify prior authorization requirements directly in this version of the policy. However, Cigna plan-level prior auth requirements for PT services vary by member benefit plan. Check the specific member's plan before billing — especially for extended courses of treatment. Contact your Cigna provider rep or check Cigna's eligibility and authorization tools to confirm prior authorization requirements for PT services before the course of care begins.
Cigna Physical Therapy Exclusions and Non-Covered Indications
Several code categories under CPG 135 are flat-out non-billable to Cigna. Know these before your team submits.
Not Medically Necessary
Two codes carry an explicit "not medically necessary" designation:
| # | Excluded Procedure |
|---|---|
| 1 | 97016 — Vasopneumatic devices |
| 2 | 97026 — Infrared therapy |
These are not covered under any circumstances under CPG 135. Remove them from your charge capture for Cigna members.
Experimental, Investigational, and Unproven
Cigna considers these codes experimental and unproven under CPG 135:
| # | Excluded Procedure |
|---|---|
| 1 | 20560 / 20561 — Needle insertion without injection (dry needling), 1–2 muscles and 3+ muscles |
| 2 | 97610 — Low-frequency, non-contact, non-thermal ultrasound |
| 3 | 97039 — Unlisted modality (when used in the PT context) |
| 4 | 97799 — Unlisted physical medicine/rehabilitation service or procedure |
| 5 | S8940 — Equestrian/hippotherapy |
| 6 | S9090 — Vertebral axial decompression |
Dry needling (20560, 20561) is the one that catches billing teams off guard most often. It's increasingly common in PT practices and it's showing up on PT claims more frequently. Cigna's position is clear: experimental. Don't bill it to Cigna expecting reimbursement under this policy.
The unlisted codes (97039, 97799) are flagged experimental when used in specific contexts. If you're using either for a legitimate, covered modality without a specific CPT code, you'll need strong supporting documentation — and even then, expect scrutiny.
Educational or Training in Nature — Not Medically Necessary
These codes are classified as educational or training in nature, not medically necessary services:
| # | Excluded Procedure |
|---|---|
| 1 | 97169 / 97170 / 97171 / 97172 — Athletic training evaluations (low, moderate, high complexity, and re-evaluation) |
| 2 | 97537 — Community/work reintegration training |
| 3 | 97545 / 97546 — Work hardening/conditioning |
| 4 | S8990 — Maintenance therapy |
| 5 | S9117 — Back school |
The maintenance therapy code S8990 is especially important. Cigna's policy states that when a patient stops progressing, treatment is no longer medically necessary. Billing S8990 essentially flags the claim as maintenance — and Cigna won't pay for it. If your team has been billing this code expecting coverage, stop now.
Work hardening (97545, 97546) landing in the educational category is a meaningful coverage policy position. If you have patients going through occupational rehabilitation programs that include work hardening, those services are not billable to Cigna under CPG 135.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Rehabilitative PT — documented functional progress | Covered | 97110, 97112, 97116, 97140, 97530, 97161–97164 | Must document progression; no improvement in 2 weeks triggers alternative plan review |
| Habilitative PT — ADL/IADL skill development | Covered | 97535, 97542, 97530 | Applies to developmental conditions; must show skills not yet developed or at risk of loss |
| PT evaluation and re-evaluation | Covered | 97161, 97162, 97163, 97164 | Complexity level must match documentation |
| Physical therapy in home health or hospice | Covered | G0151, S9131 | Skilled service requirement still applies |
| Respiratory muscle therapy | Covered | G0237, G0238, G0239, 94667, 94668 | Face-to-face requirement for G0237–G0239 |
| Orthotic/prosthetic management and training | Covered | 97760, 97761, 97763 | Initial and ongoing training covered when medically necessary |
| Dry needling | Experimental | 20560, 20561 | Not covered under CPG 135 |
| Non-contact ultrasound | Experimental | 97610 | Not covered under CPG 135 |
| Vertebral axial decompression | Experimental | S9090 | Not covered under CPG 135 |
| Hippotherapy | Experimental | S8940 | Not covered under CPG 135 |
| Maintenance therapy | Not Medically Necessary | S8990 | Covered only when patient is progressing |
| Back school | Not Medically Necessary | S9117 | Educational in nature per Cigna |
| Work hardening/conditioning | Not Medically Necessary | 97545, 97546 | Educational in nature per Cigna |
| Athletic training evaluations | Not Medically Necessary | 97169–97172 | Not covered under PT benefit |
| Vasopneumatic devices | Not Medically Necessary | 97016 | Explicitly non-covered |
| Infrared therapy | Not Medically Necessary | 97026 | Explicitly non-covered |
Cigna Physical Therapy Billing Guidelines and Action Items 2025
| # | Action Item |
|---|---|
| 1 | Audit your documentation templates before December 16, 2025. Every PT note needs to clearly answer why the service requires a licensed therapist. Generic SOAP notes won't cut it. Build a documentation standard that explicitly addresses skilled service justification for codes like 97110, 97112, and 97140. |
| 2 | Remove 97016 and 97026 from your Cigna charge capture now. These codes are non-covered. There's no medical necessity argument that overrides that. Submitting them generates denials and creates audit exposure. |
| 3 | Flag dry needling claims before they go out. If your therapists perform dry needling (CPT 20560 or 20561) and bill Cigna, those claims will deny. This is a policy-level exclusion, not a prior authorization issue. Update your billing guidelines to block these codes on Cigna claims. |
| 4 | Build a two-week and four-week progress checkpoint into your PT workflow. Cigna's CPG 135 policy sets explicit review triggers: no improvement at two weeks means consider an alternative plan; no significant improvement at four weeks may require referring provider re-evaluation. Make these checkpoints part of your clinical workflow — not just a billing afterthought. Missing them is how you end up with denied claims for services rendered after progress stalled. |
| 5 | Stop billing S8990 for Cigna. Maintenance therapy is not a covered service under CPG 135. If a patient has plateaued, the clinical record should document why treatment is still medically necessary — not default to a maintenance billing code. If the patient genuinely needs maintenance-level care, that's a conversation about the care plan, not a billing workaround. |
| 6 | Confirm prior authorization requirements plan by plan before starting extended PT. CPG 135 doesn't list specific prior auth thresholds, but Cigna plan-level requirements vary. Call to verify or check Cigna's provider portal before authorizing a multi-week PT course of care. A missed prior auth requirement is a preventable claim denial. |
| 7 | If you're billing work hardening (97545, 97546) to Cigna, reassess. These are classified as educational in nature — not medically necessary. If you have an occupational health or work rehab program, check whether those services have an alternative billing path or whether they fall outside the PT benefit entirely. |
| 8 | Talk to your compliance officer if your PT volume is high. This policy change tightens the skilled service standard and the progression requirements. If you have high PT claim volume with Cigna, a compliance review of recent claims against the updated CPG 135 criteria is worth doing before the effective date. Identify your exposure now rather than in a post-payment audit. |
| 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 cpg135_physical_therapy
Covered CPT Codes (When Medical Necessity Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 94667 | CPT | Manipulation chest wall (cupping, percussing, vibration); initial |
| 94668 | CPT | Manipulation chest wall (cupping, percussing, vibration); subsequent |
| 97010 | CPT | Hot or cold packs |
| 97012 | CPT | Traction, mechanical |
| 97014 | CPT | Electrical stimulation (unattended) |
| 97018 | CPT | Paraffin bath |
| 97022 | CPT | Whirlpool |
| 97024 | CPT | Diathermy (e.g., microwave) |
| 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 and endurance, each 15 minutes |
| 97112 | CPT | Neuromuscular reeducation of movement, balance, coordination, each 15 minutes |
| 97113 | CPT | Aquatic therapy with therapeutic exercises, each 15 minutes |
| 97116 | CPT | Gait training (includes stair climbing), each 15 minutes |
| 97124 | CPT | Massage (effleurage, petrissage, and/or tapotement), each 15 minutes |
| 97140 | CPT | Manual therapy techniques (mobilization/manipulation, manual lymphatic drainage, manual traction), each 15 minutes |
| 97150 | CPT | Therapeutic procedures, group (2 or more individuals) |
| 97161 | CPT | Physical therapy evaluation: low complexity |
| 97162 | CPT | Physical therapy evaluation: moderate complexity |
| 97163 | CPT | Physical therapy evaluation: high complexity |
| 97164 | CPT | Re-evaluation of physical therapy established plan of care |
| 97530 | CPT | Therapeutic activities, direct one-on-one patient contact, each 15 minutes |
| 97535 | CPT | Self-care/home management training (ADL and compensatory training), each 15 minutes |
| 97542 | CPT | Wheelchair management (assessment, fitting, training), each 15 minutes |
| 97750 | CPT | Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report |
| 97760 | CPT | Orthotic(s) management and training (including assessment and fitting), each 15 minutes |
| 97761 | CPT | Prosthetic(s) training, upper and/or lower extremity(ies), initial encounter, each 15 minutes |
| 97763 | CPT | Orthotic(s)/prosthetic(s) management and/or training, each 15 minutes |
Covered HCPCS Codes (When Medical Necessity Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| G0151 | HCPCS | Services by a qualified physical therapist in home health or hospice, each 15 minutes |
| G0237 | HCPCS | Therapeutic procedures to increase strength or endurance of respiratory muscles, one on one, face to face |
| G0238 | HCPCS | Therapeutic procedures to improve respiratory function (other than G0237), one on one, face to face |
| G0239 | HCPCS | Therapeutic procedures to improve respiratory function or increase strength/endurance of respiratory muscles, group |
| S9131 | HCPCS | Physical therapy in the home, per diem |
Not Covered / Experimental CPT and HCPCS Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 97016 | CPT | Vasopneumatic devices | Not medically necessary |
| 97026 | CPT | Infrared | Not medically necessary |
| 20560 | CPT | Needle insertion without injection, 1–2 muscles (dry needling) | Experimental, investigational, unproven |
| 20561 | CPT | Needle insertion without injection, 3 or more muscles (dry needling) | Experimental, investigational, unproven |
| 97610 | CPT | Low-frequency, non-contact, non-thermal ultrasound | Experimental, investigational, unproven |
| 97039 | CPT | Unlisted modality | Experimental, investigational, unproven (in PT context) |
| 97799 | CPT | Unlisted physical medicine/rehabilitation service or procedure | Experimental, investigational, unproven (in PT context) |
| S8940 | HCPCS | Equestrian/hippotherapy, per session | Experimental, investigational, unproven |
| S9090 | HCPCS | Vertebral axial decompression, per session | Experimental, investigational, unproven |
Educational / Training in Nature — Not Medically Necessary
| Code | Type | Description |
|---|---|---|
| 97169 | CPT | Athletic training evaluation, low complexity |
| 97170 | CPT | Athletic training evaluation, moderate complexity |
| 97171 | CPT | Athletic training evaluation, high complexity |
| 97172 | CPT | Re-evaluation of athletic training established plan of care |
| 97537 | CPT | Community/work reintegration training |
| 97545 | CPT | Work hardening/conditioning; initial 2 hours |
| 97546 | CPT | Work hardening/conditioning; each additional hour |
| S8990 | HCPCS | Physical or manipulative therapy performed for maintenance rather than restoration |
| S9117 | HCPCS | Back school, per visit |
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