UnitedHealthcare Medicare Advantage physical therapy coverage: codes, telehealth, limits and prior authorization
The short answerUnitedHealthcare Medicare Advantage requires prior authorization for outpatient PT in offices and outpatient hospitals. The evaluation is exempt, and up to 6 visits in 8 weeks skip clinical review, but the request is still required.
By Javier Alvarez · Updated · 1 min read
1 row: UnitedHealthcare Medicare Advantage. Public policy, not the member's benefits.
UnitedHealthcare Medicare Advantage
UnitedHealthcare Medicare Advantage, outpatient therapy prior authorization · All states
| 97110 | Limited (on the prior authorization code list) [1] |
|---|---|
| 97112 | Limited (on the prior authorization code list) [1] |
| 97140 | Limited (on the prior authorization code list) [1] |
| 97161 | Not named (the initial evaluation does not need prior authorization, but the evaluation results and care plan must be submitted with the request.) [1] |
| 97164 | Limited (on the prior authorization code list) [1] |
| 97530 | Limited (on the prior authorization code list) [1] |
| Where it applies | Applies to in-network providers for UnitedHealthcare Medicare Advantage individual (including chronic SNPs) and group retiree plans, plus added Arizona and California plans from Feb. 1, 2026. Excluded: out-of-network providers, Dual Complete, nursing home and assisted living plans, and several named regional plans. Reviews use applicable LCDs, CMS Chapter 15 criteria and InterQual. [1] |
| Other codes | The prior authorization code list includes 97110, 97112, 97116, 97140, 97164, 97530, 97535, 97542 and 97750, plus modalities such as 97012 to 97036. [1] |
| Telehealth POS | Therapy performed in the home (place of service Home) is excluded from the prior authorization program; existing Home Health program rules still apply. [1] |
| Visit limits | Up to 6 visits of the initial plan of care are covered without clinical review when they happen within 8 weeks, but the request must still be submitted. A plan of care with more than 6 visits or more than 8 weeks gets a medical necessity review. The 6-visit window applies if the member is new to the office, has a new condition, or had a gap in care of 90 days or more. [1] |
| Prior authorization | Prior authorization is required for outpatient PT delivered in an office or outpatient hospital, not in the home. The initial evaluation does not need it, but the request for the full plan of care (duration and number of visits) must be filed through the UnitedHealthcare Provider Portal, with the evaluation results and care plan. [1] |
What UnitedHealthcare Medicare Advantage's documents say
The table above has every field we found for UnitedHealthcare Medicare Advantage, with numbered sources. In short:
- Prior authorization. Prior authorization is required for outpatient PT delivered in an office or outpatient hospital, not in the home. The initial evaluation does not need it, but the request for the full plan of care (duration and number of visits) must be filed through the UnitedHealthcare Provider Portal, with the evaluation results and care plan.
- Visit limits. Up to 6 visits of the initial plan of care are covered without clinical review when they happen within 8 weeks, but the request must still be submitted. A plan of care with more than 6 visits or more than 8 weeks gets a medical necessity review. The 6-visit window applies if the member is new to the office, has a new condition, or had a gap in care of 90 days or more.
- Telehealth POS. Therapy performed in the home (place of service Home) is excluded from the prior authorization program; existing Home Health program rules still apply.
- Codes. 97110, 97112, 97140, 97164 and 97530 are limited. 97161 is not named in this policy.
Physical therapy coverage at other national payers
Medicare, UnitedHealthcare Commercial, Aetna, Cigna, Humana and TRICARE.
Check UnitedHealthcare Medicare Advantage's claim against the row
Before the claim goes out, compare it with the row above: the evaluation code matches the complexity you documented, the timed codes fit the minutes, any prior authorization covers the visit, and the plan of care is signed when the payer asks for it. The physical therapy table compares UnitedHealthcare Medicare Advantage with every other payer we checked.