CommercialCoverageHigh impact
Therapies (Speech, Physical and Occupational) 8.01.24
Excellus BlueCross BlueShield·Physical Therapy, Occupational Therapy, PM&R (Physical Medicine & Rehab) +2 more·Therapy & Rehabilitation
Effective date
Nov 20, 2025
We identified it
Jun 20, 2026
Summary
Excellus BlueCross BlueShield updated their therapy services policy (Speech, Physical, and Occupational) with new medical necessity criteria and specific exclusions. The policy establishes stricter requirements for initial therapy requests, continuation of services, and explicitly lists non-covered services including certain voice therapies, maintenance programs, and investigational treatments.
Action Required
Before November 20, 2025: Billing team must update prior authorization processes for all therapy services (PT, OT, ST) to ensure standardized assessments showing at least 1.5 standard deviations below mean (score of 77 or below) are documented for pediatric cases. Update encounter forms to require documentation of functional improvement expectations within 2 months for initial requests. Providers must document maintenance service level has not been achieved and show objective improvement measures for continuation requests. Stop billing for explicitly excluded services including oral myofunctional disorders, pragmatic language disorders, sensory integration therapy, hippotherapy, dry needling, and maintenance programs as these will be denied.