TL;DR: Cigna Healthcare modified CPG155, its occupational therapy coverage policy, effective December 16, 2025. Here's what billing teams need to do before claims start hitting the new criteria.
Cigna Healthcare updated CPG155 (cpg155_occupational_therapy), its occupational therapy coverage policy governing a broad set of OT-related CPT and HCPCS codes. The changes affect 42 CPT codes and eight HCPCS codes—ranging from evaluations (CPT 97165–97168) and therapeutic procedures (CPT 97110, 97530, 97535) to home health codes (G0152, G0158, G0160) and codes Cigna now flags as experimental or not medically necessary. If your practice or facility bills OT services to Cigna members, this update changes how you document and support medical necessity across nearly every OT service line.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Cigna Healthcare |
| Policy | Occupational Therapy (CPG155) |
| Policy Code | cpg155_occupational_therapy |
| Change Type | Modified |
| Effective Date | December 16, 2025 |
| Impact Level | High |
| Specialties Affected | Occupational therapy, home health, rehabilitation, orthotic/prosthetic services |
| Key Action | Audit OT documentation for medical necessity criteria and flag claims using experimental or educational codes before December 16, 2025 |
Cigna Occupational Therapy Coverage Criteria and Medical Necessity Requirements 2025
The core test Cigna applies under this coverage policy is simple: can this service be safely performed without a licensed therapist? If the answer is yes, Cigna will not pay for it.
That's not a minor nuance—it's the policy's central organizing principle. Cigna explicitly states that a service is not a skilled therapy service just because a therapist performs it. If the service could be self-administered, or safely done by an unskilled person without therapist supervision, Cigna will not count it toward medical necessity.
The same logic applies to caregiver limitations. The fact that a competent unskilled caregiver isn't available doesn't make a non-skilled service billable as skilled OT. If the patient's care can proceed through a home exercise program, self-management program, restorative nursing program, or caregiver-assisted program, Cigna considers occupational therapy services not medically necessary.
Rehabilitative vs. Habilitative Services
Cigna splits OT services into two distinct categories, and your documentation strategy needs to match which one applies.
Rehabilitative OT covers services that improve, adapt, or restore functions lost due to illness, injury, loss of a body part, or congenital abnormality. The key phrase is "reasonable period of time." Cigna sets hard checkpoints:
| # | Covered Indication |
|---|---|
| 1 | No improvement after two weeks: Try an alternative treatment plan. |
| 2 | No significant improvement after four weeks total: Referring provider re-evaluation may be required. |
| 3 | No progression toward established goals at any point: Services are no longer medically necessary. |
Document progress at every visit. Cigna will look for measurable change, not just continued treatment. If your documentation doesn't show forward movement, expect a claim denial.
Habilitative OT covers services that help a patient keep, develop, or improve skills needed for activities of daily living (ADLs) or instrumental activities of daily living (IADLs)—skills that haven't developed yet but normally would, or that are at risk of being lost. A common example is therapy for a child not walking at the expected developmental age.
The distinction matters for billing. Rehabilitative services restore function that existed before. Habilitative services build or maintain function that may never have existed at baseline. Your diagnosis codes and treatment notes need to support whichever category you're billing.
Prior Authorization and Reimbursement Considerations
Cigna's occupational therapy billing guidelines don't spell out a universal prior authorization threshold in this policy document, but that doesn't mean you're in the clear. Prior auth requirements for OT vary by plan type and benefit design. Confirm PA requirements with the specific Cigna plan before you bill CPT 97165 (low-complexity OT evaluation), 97166 (moderate-complexity), or 97167 (high-complexity)—these evaluation codes trigger the most scrutiny on initial claims.
For reimbursement under home health, codes G0152, G0158, and G0160 fall under specific home health and hospice billing rules. G0152 covers services by a qualified OT in a home health or hospice setting. G0158 covers services by a qualified OT assistant in the same setting. G0160 covers OT services in the home health setting for established plan-of-care services. Bill these only when the service genuinely requires skilled OT judgment—Cigna will apply the same skilled-service test here as anywhere else.
Cigna Occupational Therapy Exclusions and Non-Covered Indications
Cigna carves out three categories of non-covered OT services under CPG155. Know these before you bill.
Educational or Training in Nature — Not Medically Necessary
Cigna does not consider these services medically necessary OT:
| # | Excluded Procedure |
|---|---|
| 1 | CPT 97169, 97170, 97171, 97172 — Athletic training evaluations (low, moderate, and high complexity, plus re-evaluation). Cigna doesn't recognize athletic training evaluations as skilled OT services. |
| 2 | CPT 97537 — Community/work reintegration training (shopping, transportation, money management). Cigna treats this as educational or training in nature. |
| 3 | CPT 97545, 97546 — Work hardening/conditioning (initial two hours and each additional hour). Same classification. |
| 4 | HCPCS S8990 — Physical or manipulative therapy for maintenance rather than restoration. This one is especially important: if you're billing maintenance-level OT, Cigna won't pay it. |
| 5 | HCPCS S9117 — Back school, per visit. |
Billing any of these to Cigna is a direct path to claim denial. Remove them from your Cigna charge capture now.
Experimental, Investigational, or Unproven
Cigna classifies these as not meeting the standard for clinical evidence:
| # | Excluded Procedure |
|---|---|
| 1 | CPT 20560 — Needle insertion(s) without injection(s), one or two muscles (dry needling) |
| 2 | CPT 20561 — Needle insertion(s) without injection(s), three or more muscles |
| 3 | CPT 97610 — Low-frequency, non-contact, non-thermal ultrasound |
| 4 | CPT 97039 — Unlisted modality (when used in an OT context) |
| 5 | CPT 97799 — Unlisted physical medicine/rehabilitation service or procedure (same) |
| 6 | HCPCS S8940 — Equestrian/hippotherapy, per session |
Dry needling (CPT 20560 and 20561) is worth calling out specifically. Some OTs bill this—and some payers cover it. Cigna does not. If your OTs perform dry needling, document it separately and do not submit it under this coverage policy.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Skilled OT evaluation (low, moderate, high complexity) | Covered | CPT 97165, 97166, 97167 | Must meet skilled-service criteria |
| Re-evaluation of established OT plan | Covered | CPT 97168 | Required if no progress at 4 weeks |
| Therapeutic exercises, neuromuscular re-education, aquatic therapy, gait training | Covered | CPT 97110, 97112, 97113, 97116 | Must document measurable progress |
| Manual therapy techniques | Covered | CPT 97140 | Skilled supervision required |
| Group therapeutic procedures | Covered | CPT 97150 | Still requires skilled OT oversight |
| Therapeutic activities (direct, one-on-one) | Covered | CPT 97530 | Key code for functional OT treatment |
| Self-care/home management training (ADL, IADL) | Covered | CPT 97535 | Supports habilitative OT claims |
| Assistive technology assessment | Covered | CPT 97755 | Document functional need clearly |
| Orthotic management and training | Covered | CPT 97760, 97763 | Assessment and fitting included |
| Prosthetic training, upper/lower extremity | Covered | CPT 97761 | Initial prosthetic encounter |
| Modalities (hot/cold, electrical stimulation, ultrasound, paraffin, whirlpool, etc.) | Covered | CPT 97010–97036 | Must be medically necessary, not routine |
| Home health OT by qualified OT | Covered | G0152, G0160 | Skilled-service test applies |
| Home health OT by OTA | Covered | G0158 | Must be under appropriate supervision |
| PACE program OT | Covered | G0129 | Skilled criteria still apply |
| In-home OT, per diem | Covered | S9129 | Confirm plan-level coverage |
| Athletic training evaluations | Not Covered | CPT 97169, 97170, 97171, 97172 | Educational/training in nature |
| Work hardening/conditioning | Not Covered | CPT 97545, 97546 | Educational/training in nature |
| Community/work reintegration training | Not Covered | CPT 97537 | Educational/training in nature |
| Maintenance therapy | Not Covered | HCPCS S8990 | Not restorative |
| Back school | Not Covered | HCPCS S9117 | Educational in nature |
| Dry needling (1–2 or 3+ muscles) | Experimental | CPT 20560, 20561 | No coverage under this policy |
| Low-frequency non-contact ultrasound | Experimental | CPT 97610 | Investigational per Cigna |
| Hippotherapy | Experimental | HCPCS S8940 | No clinical evidence threshold met |
| Unlisted modality / unlisted rehab service | Experimental (OT context) | CPT 97039, 97799 | Experimental when billed as OT |
Cigna Occupational Therapy Billing Guidelines and Action Items 2025
Act on these before December 16, 2025. That's the effective date. Don't wait until a denial tells you something changed.
| # | Action Item |
|---|---|
| 1 | Audit your Cigna charge capture for non-covered codes. Pull every CPT and HCPCS code your team bills to Cigna under OT. Flag CPT 97169–97172, 97537, 97545, 97546, and HCPCS S8990 and S9117. These will not reimburse. Remove them from your Cigna fee schedule templates before December 16, 2025. |
| 2 | Update documentation templates to capture two-week and four-week progress benchmarks. Cigna's medical necessity criteria include explicit timelines. Your OT notes must show measurable progress at the two-week mark. If there's no improvement, document the alternative treatment plan. At four weeks without significant progress, document whether a referring provider re-evaluation was ordered. |
| 3 | Train your OTs and OTAs on the skilled-service test. Every note should answer one question: why does this service require a licensed OT? If the note doesn't answer that, Cigna can and will deny it. This applies to all covered codes—including high-volume codes like CPT 97530 (therapeutic activities) and 97535 (self-care/home management training). |
| 4 | Separate rehabilitative and habilitative claims clearly. Your treatment notes, diagnosis codes, and goals must reflect which category applies. Habilitative OT claims require documentation showing the skill or function was never fully developed, not that it was lost. This distinction will matter when Cigna reviews your claim. |
| 5 | Stop billing CPT 20560 and 20561 for dry needling under Cigna OT claims. Cigna classifies these as experimental under this coverage policy. If your OTs perform dry needling, check whether any other Cigna policy covers it—but under CPG155, these codes will be denied. |
| 6 | Verify prior authorization requirements at the plan level before billing. This policy doesn't define a universal PA threshold, but many Cigna plans require prior auth for OT. Check each member's benefit design before the first claim goes out. This is especially true for CPT 97165–97167 (OT evaluations) and for home health codes G0152, G0158, and G0160. |
| 7 | If your billing mix includes complex habilitative cases or pediatric OT with developmental diagnoses, loop in your compliance officer. The line between habilitative and rehabilitative OT isn't always clean, and Cigna's documentation requirements are strict. A compliance review before December 16, 2025 is worth the time. |
| 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 Occupational Therapy Under cpg155_occupational_therapy
Covered CPT Codes (When Medical Necessity Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 97010 | CPT | Application of modality; hot or cold packs |
| 97012 | CPT | Application of modality; traction, mechanical |
| 97014 | CPT | Application of modality; electrical stimulation (unattended) |
| 97016 | CPT | Application of modality; vasopneumatic devices |
| 97018 | CPT | Application of modality; paraffin bath |
| 97022 | CPT | Application of modality; whirlpool |
| 97024 | CPT | Application of modality; diathermy (e.g., microwave) |
| 97026 | CPT | Application of modality; infrared |
| 97028 | CPT | Application of modality; ultraviolet |
| 97032 | CPT | Application of modality; electrical stimulation (manual), each 15 minutes |
| 97033 | CPT | Application of modality; iontophoresis, each 15 minutes |
| 97034 | CPT | Application of modality; contrast baths, each 15 minutes |
| 97035 | CPT | Application of modality; ultrasound, each 15 minutes |
| 97036 | CPT | Application of modality; 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 |
| 97140 | CPT | Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), each 15 minutes |
| 97150 | CPT | Therapeutic procedure(s), group (2 or more individuals) |
| 97165 | CPT | Occupational therapy evaluation, low complexity |
| 97166 | CPT | Occupational therapy evaluation, moderate complexity |
| 97167 | CPT | Occupational therapy evaluation, high complexity |
| 97168 | CPT | Re-evaluation of occupational 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 |
| 97755 | CPT | Assistive technology assessment, each 15 minutes |
| 97760 | CPT | Orthotic(s) management and training (including assessment and fitting), each 15 minutes |
| 97761 | CPT | Prosthetic(s) training, upper and/or lower extremity, initial encounter, each 15 minutes |
| 97763 | CPT | Orthotic(s)/prosthetic(s) management and/or training, upper/lower extremity, each 15 minutes |
Covered HCPCS Codes (When Medical Necessity Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| G0129 | HCPCS | Occupational therapy services requiring the skills of a qualified OT, furnished in a PACE program |
| G0152 | HCPCS | Services by a qualified occupational therapist in the home health or hospice setting, each 15 minutes |
| G0158 | HCPCS | Services by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes |
| G0160 | HCPCS | Services by a qualified occupational therapist in the home health setting, established plan of care |
| S9129 | HCPCS | Occupational therapy, in the home, per diem |
Not Covered CPT and HCPCS Codes (Educational or Training in Nature)
| Code | Type | Description | Reason |
|---|---|---|---|
| 97169 | CPT | Athletic training evaluation, low complexity | Educational/training in nature — not medically necessary |
| 97170 | CPT | Athletic training evaluation, moderate complexity | Educational/training in nature — not medically necessary |
| 97171 | CPT | Athletic training evaluation, high complexity | Educational/training in nature — not medically necessary |
| 97172 | CPT | Re-evaluation of athletic training established plan of care | Educational/training in nature — not medically necessary |
| 97537 | CPT | Community/work reintegration training | Educational/training in nature — not medically necessary |
| 97545 | CPT | Work hardening/conditioning; initial 2 hours | Educational/training in nature — not medically necessary |
| 97546 | CPT | Work hardening/conditioning; each additional hour | Educational/training in nature — not medically necessary |
| S8990 | HCPCS | Physical or manipulative therapy for maintenance rather than restoration | Educational/training in nature — not medically necessary |
| S9117 | HCPCS | Back school, per visit | Educational/training in nature — not medically necessary |
Experimental, Investigational, or Unproven Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 20560 | CPT | Needle insertion(s) without injection(s); 1 or 2 muscles | Experimental/investigational/unproven |
| 20561 | CPT | Needle insertion(s) without injection(s); 3 or more muscles | Experimental/investigational/unproven |
| 97610 | CPT | Low-frequency, non-contact, non-thermal ultrasound, including topical application(s) | Experimental/investigational/unproven |
| 97039 | CPT | Unlisted modality (specify type and time if constant attendance) | Experimental/investigational/unproven when used in OT context |
| 97799 | CPT | Unlisted physical medicine/rehabilitation service or procedure | Experimental/investigational/unproven when used in OT context |
| S8940 | HCPCS | Equestrian/hippotherapy, per session | Experimental/investigational/unproven |
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