TL;DR: Cigna Healthcare modified CPG295 (cpg295_ppt) governing physical performance test or measurement coverage, effective November 15, 2025. CPT 97750 remains the billable code when criteria are met — but CPT 97537, 97545, and 97546 are explicitly excluded as not medically necessary under this policy.
Cigna Healthcare updated its Cigna physical performance test coverage policy under policy code CPG295 (cpg295_ppt), with an effective date of November 15, 2025. The update clarifies medical necessity criteria for CPT 97750 — physical performance testing — and draws a hard line around three codes (97537, 97545, 97546) classified as educational or training in nature. If your team bills physical therapy or occupational therapy services for neurological or musculoskeletal patients, this policy affects your charge capture and your exposure to claim denial.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Cigna Healthcare |
| Policy | Physical Performance Test or Measurement (CPG295) |
| Policy Code | cpg295_ppt |
| Change Type | Modified |
| Effective Date | November 15, 2025 |
| Impact Level | Medium |
| Specialties Affected | Physical Therapy, Occupational Therapy, Pulmonary Rehabilitation, Physiatry, Neurological Rehab |
| Key Action | Audit charge capture for CPT 97750 to confirm direct one-on-one contact documentation, and stop bundling 97537, 97545, or 97546 with performance testing services |
Cigna Physical Performance Test Coverage Criteria and Medical Necessity Requirements 2025
The Cigna physical performance test coverage policy under CPG295 covers CPT 97750 when two conditions are met: the patient has a neurological or musculoskeletal condition, and there is a documented clinical need to evaluate the ability to perform specific tasks. That's the standard. Everything else in this policy is built around what doesn't meet that standard.
Medical necessity for CPT 97750 is not met if you're billing it as part of a routine assessment or re-evaluation of rehabilitation services. Cigna is explicit about this. The test must serve a distinct clinical purpose — not act as a workaround to capture evaluation time that should be billed under evaluation and management or re-evaluation codes.
The coverage policy also specifies that direct one-on-one patient contact is required. Remote monitoring, group sessions, or indirect supervision won't support a 97750 claim. Document the one-on-one contact explicitly in the clinical note or expect a denial.
Physical performance testing billing under this policy includes a broad range of test types. Isokinetic testing — which measures strength, endurance, and power through specific movements of the trunk or extremities — qualifies. So do functional capacity evaluations, balance-specific tests like the timed up-and-go test, the 6-minute walk test, and computerized oxygen saturation reports under increasing stress, when performed under a PT or OT plan of care for pulmonary rehabilitation patients. Standardized testing batteries also qualify when incorporated into the performance test.
One code overlap you need to watch: Cigna's billing guidelines state it's not appropriate to bill from the 95851–95852 series alongside CPT 97750. CPT 95851 and 95852 cover range of motion measurements. If your team is stacking these with 97750, pull those claims for review before November 15, 2025. Prior authorization requirements are not specified in this policy update, but that does not mean you skip the PA check — confirm through Cigna's provider portal for your specific plan types and specialties.
Cigna Physical Performance Test Exclusions and Non-Covered Indications
Three codes are flat-out excluded under this coverage policy. Cigna classifies CPT 97537, 97545, and 97546 as educational or training in nature — not medically necessary. That classification carries real reimbursement consequences.
CPT 97537 is community and work reintegration training — shopping, transportation, money management, and similar functional activities. CPT 97545 covers work hardening and conditioning for the initial two hours. CPT 97546 covers each additional hour of work hardening or conditioning beyond that first block.
The real issue here is how often these codes get billed alongside or in lieu of 97750 when a clinician is working on functional performance goals. They look similar from a workflow standpoint. But Cigna draws a clear line: training and conditioning services — even when tied to functional rehabilitation goals — are not physical performance tests. Billing them as such is a compliance problem, not just a billing dispute.
If your practice uses CPT 97545 or 97546 for work hardening programs, those services are separately non-covered under this policy. Build that into your financial counseling conversations with patients before treatment begins.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Physical performance testing for neurological or musculoskeletal conditions requiring task evaluation | Covered | CPT 97750 | Direct one-on-one contact required; written report required |
| Isokinetic testing (strength, endurance, power — trunk or extremities) | Covered | CPT 97750 | Must be part of documented plan of care |
| Functional capacity evaluation | Covered | CPT 97750 | Must not substitute for evaluation/re-evaluation codes |
| Balance testing (e.g., timed up-and-go test) | Covered | CPT 97750 | Standardized test batteries acceptable |
| 6-minute walk test with computerized oxygen saturation report | Covered | CPT 97750 | Must be under PT or OT plan of care for pulmonary rehab patients |
| Routine rehabilitation assessment or re-evaluation | Not Covered | CPT 97750 | Use appropriate evaluation/re-evaluation codes instead |
| Billing 95851–95852 alongside 97750 | Not Covered | CPT 95851, 95852 | Cannot report range of motion codes in addition to 97750 |
| Community/work reintegration training | Not Covered | CPT 97537 | Classified as educational or training — not medically necessary |
| Work hardening/conditioning (initial 2 hours) | Not Covered | CPT 97545 | Classified as educational or training — not medically necessary |
| Work hardening/conditioning (additional hours) | Not Covered | CPT 97546 | Classified as educational or training — not medically necessary |
Cigna Physical Performance Test Billing Guidelines and Action Items 2025
Here's what your billing team needs to do before November 15, 2025.
| # | Action Item |
|---|---|
| 1 | Audit your 97750 claims from the past 90 days. Look specifically for two things: claims that lack explicit documentation of direct one-on-one patient contact, and claims where 97750 was billed as part of a routine assessment rather than a distinct clinical evaluation. Flag any claim that could be reclassified as a re-evaluation. This audit will tell you where your denial exposure lives. |
| 2 | Pull any claims that include CPT 95851 or 95852 billed alongside 97750. Cigna explicitly prohibits this combination. If you're billing range of motion codes with physical performance testing on the same date of service, those claims are non-compliant under CPG295. Correct the pattern now — don't wait for the denials. |
| 3 | Remove CPT 97537, 97545, and 97546 from any charge capture templates used for Cigna patients. These codes are not covered under this policy. Billing them will generate claim denial. If your work hardening or community reintegration services are clinically necessary and you believe coverage exists through another pathway, talk to your compliance officer before billing those codes for Cigna members. |
| 4 | Update your documentation templates to capture one-on-one contact explicitly. A physical performance test under 97750 requires direct contact. "Patient seen in therapy gym" is not enough. The note must confirm the clinician was physically present and engaged one-on-one with the patient for the duration of the test. Add a checkbox or structured field to your documentation workflow to make this automatic. |
| 5 | Train your therapists on the routine assessment exclusion. This is where the gray area lives. A therapist doing a functional evaluation at the start of a care episode or at a progress check point may be tempted to bill 97750 because it reflects what they did clinically. But if the purpose is to assess overall rehabilitation progress — rather than to evaluate performance of specific tasks for clinical decision-making — the code doesn't fit. This distinction needs to be part of your coder-clinician education before the effective date. |
| 6 | Verify prior authorization requirements by plan type. CPG295 does not specify a prior authorization requirement in the policy text, but Cigna's PA requirements vary by product and benefit design. Check Cigna's provider portal or your Cigna provider agreement for plan-specific rules before assuming PA is not needed for 97750. |
If your practice has significant volume in work hardening, community reintegration, or pulmonary rehab — and you've been billing 97537, 97545, 97546, or stacking range of motion codes with 97750 — this policy change creates meaningful denial risk. Talk to your compliance officer about a look-back review before November 15, 2025.
| 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 Performance Testing Under CPG295
Covered CPT Codes (When Medical Necessity Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 97750 | CPT | Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes |
Not Covered CPT Codes — Classified as Educational or Training in Nature
| Code | Type | Description | Reason |
|---|---|---|---|
| 97537 | CPT | Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities), direct one-on-one contact by the provider, each 15 minutes | Classified as educational or training in nature — not medically necessary under CPG295 |
| 97545 | CPT | Work hardening/conditioning; initial 2 hours | Classified as educational or training in nature — not medically necessary under CPG295 |
| 97546 | CPT | Work hardening/conditioning; each additional hour (list separately in addition to code for primary procedure) | Classified as educational or training in nature — not medically necessary under CPG295 |
Note on ICD-10 Codes: The CPG295 policy document does not specify ICD-10-CM diagnosis codes. Coverage for CPT 97750 is tied to the patient's neurological or musculoskeletal condition diagnosis. Confirm that the diagnosis on your claim accurately reflects the condition driving the need for physical performance testing. Diagnosis codes that suggest routine wellness or general rehabilitation without a specific neurological or musculoskeletal condition will undermine the medical necessity case.
Get the Full Picture for CPT 97750
Track this policy across versions, search 1,500+ policies by CPT code, and get real-time alerts when any payer changes coverage.