LCD L34560 Home Health Occupational Therapy: Medicare…

Where this LCD applies

Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.

Contracts that apply LCD L34560
Contract	Contractor	Type	States
11004	Palmetto GBA	A and B and HHH MAC	AL AR FL GA IL IN KY LA MS NC NM OH OK SC TN TX

Billing and coding: diagnoses and procedure codes

Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A53053 (Billing and Coding: CPT Code 97755 - Assistive Technology Assessment), Billing and Coding A53057 (Billing and Coding: Home Health Occupational Therapy) carry the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.

A53053: Billing and Coding: CPT Code 97755 - Assistive Technology Assessment (Billing and Coding, effective 2022-05-19)

Covered ICD-10-CM codes: 0; 0 groups
Non-covered ICD-10-CM codes: 0
Procedure codes listed: 1
Full article: cms.gov record

Procedure codes: 97755.

A53057: Billing and Coding: Home Health Occupational Therapy (Billing and Coding, effective 2026-10-01)

Covered ICD-10-CM codes: 7833; 1 group
Non-covered ICD-10-CM codes: 0
Procedure codes listed: 61
Full article: cms.gov record

First 24 covered ICD-10-CM codes in A53057
ICD-10-CM	Description (FY2027)
A18.01	—
A18.02	—
A52.16	—
B91	Sequelae of poliomyelitis
E08.40	—
E08.42	—
E08.44	—
E08.52	—
E08.610	—
E08.618	—
E09.40	—
E09.42	—
E09.44	—
E09.52	—
E09.610	—
E09.618	—
E10.40	—
E10.42	—
E10.44	—
E10.52	—
E10.610	—
E10.618	—
E11.40	—
E11.42	—

Procedure codes: 29065, 29075, 29085, 29086, 29105, 29125, 29126, 29130, 29131, 29200, 29240, 29260, 29280, 29345, 29365, 29405, 29505, 29515, 29520, 29530, 29540, 29550, 29799, 90901, 92526, 92610, 95851, 95852, 96125, 97016, 97018, 97026, 97032, 97033, 97034, 97035, 97110, 97112, 97124, 97140 and 21 more in the article.

Coverage indications, limitations and medical necessity

Although rehabilitative services are provided by physical therapy (PT), speech therapy (ST) and occupational therapy (OT), this policy only addresses OT.

OT is an integral component of rehabilitative services in the areas of physical, cognitive and psychosocial impairment. OT is based on purposeful, goal directed activity (occupation). The goal of OT is to prevent, improve or restore physical and/or cognitive impairment following disease or injury.

Occupational therapists utilize clinical history, observation, interview, standardized testing and assessment of activities of daily living (ADLs) skills, work skills and leisure skills to characterize individuals with impairments, functional limitations and disabilities. The results of these assessments are used to identify structural impairments and functional limitations and to design an individualized plan of treatment to assist in improving or restoring function. All OT services must be performed by or under the supervision of a skilled qualified occupational therapist.

1. The treatment approach includes:

• Evaluation

• Basic activities of daily living (BADLs) training

• Instrumental activities of daily living (IADLs) training

• Muscle re-education

• Cognitive training

• Perceptual motor training

• Fine motor coordination/strengthening/coordination

• Orthotics (splinting)

• Adaptive equipment fabrication and training

• Environment modification recommendations/training

• Patient/caregiver education/training

• Transfer training

• Functional mobility training

• Manual therapy

• Physical agent modalities

• Neurodevelopment training

2. Coverage of skilled rehabilitation services is contingent upon the beneficiary's need for skilled care whether the goal of therapy includes maintenance or improvement.

3. The pressing need for a service, or the lack of availability of unskilled personnel to render the service with the necessary frequency does not itself make a service skilled. However, some services that would not normally be considered skilled therapy may require the skilled services of a therapy professional because of a special complicating medical factor. This must be clearly evident in the medical record.

4. OT is only covered when it is rendered under a written plan of treatment established by the physician and the qualified occupational therapist and signed (including professional identity) and dated by the physician. The plan of treatment should contain, at a minimum, all diagnoses, long term treatment goals and type, amount, duration and frequency of therapy services. The physician should review the plan of treatment every 60 days.

5. The physician and/or therapist must document the patient's functional limitations in terms that are objective and measurable.

6. Rehabilitation services for vision impairment: Medicare beneficiaries who are blind or visually impaired are eligible for physician prescribed rehabilitation services on the same basis as beneficiaries with other medical conditions.

Maintenance Therapy

Coverage of skilled rehabilitation services is contingent upon a beneficiary's need for skilled care. When a program to maintain or reduce decline in functional status requires the skills of a licensed therapist to be performed safely and effectively, provision of skilled services for the execution of that therapy program is covered. The skilled need must come from the nature of the service being rendered and the patient's unique circumstance. The provision of therapy services by skilled therapy personnel does not itself make the service one that requires skilled care.

Restorative/Rehabilitative therapy

In evaluating a claim for skilled therapy that is restorative/rehabilitative (i.e., whose goal and/or purpose is to reverse, in whole or in part, a previous loss of function), it would be entirely appropriate to consider the beneficiary’s potential for improvement from the services.

Maintenance therapy

Even if no improvement is expected, under the home health (HH) coverage standards, skilled therapy services are covered when an individualized assessment of the patient’s condition demonstrates that skilled care is necessary for the performance of a safe and effective maintenance program to maintain the patient’s current condition or prevent or slow further deterioration. Skilled maintenance therapy may be covered when the particular patient’s special medical complications or the complexity of the therapy procedures require skilled care.

SPECIFIC PROCEDURE AND MODALITY GUIDELINES:

Fabrication/Application of Casts, Splints and Strapping

Fabrication and application of casts, splints and strapping will be considered reasonable and necessary if used to support weak, post-surgical or ineffective joints/muscles, facilitate increased motor response, to assist in compensation in a permanent loss of motor function, reduce/correct joint limitations/deformities and/or protect body parts from injury, thus enhancing the performance of tasks or movements. The casts, splints and strapping are often used in conjunction with therapeutic exercise, functional training, other interventions and should be selected in the context of patients' needs, social/culture environments, BADLs and IADLs.

BODY AND UPPER EXTREMITY CASTS:

Application of long arm

May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue.

Application of short arm

May be indicated for the forearm, wrist and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue.

Application of hand and lower forearm

May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue.

Application of finger cast

May be indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures or other deformities involving soft tissue.

SPLINTS:

Application of long arm splint

Application of short arm splint

May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprain/strains, tendinitis, post-op reconstruction, treatment of spasticity, contractures or other deformities involving soft tissue.

Application of finger splint

STRAPPING:

Strapping of thorax

May be indicated for the thoracic spine, lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, contractures, or other deformities involving soft tissue.

Strapping of low back

May be indicated for the lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprain/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue.

Strapping of shoulder

May be indicated for any portion of the shoulder girdle complex or rib cage in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue.

Strapping of elbow or wrist

May be indicated for the elbow or wrist when there is involvement of the humerus, forearm, wrist or hand in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, edema, scar management, contractures or other deformities involving soft tissue.

Strapping of hand or finger

May be indicated where there is involvement of the hand or fingers in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, edema, scar management, contractures or other deformities involving soft tissue.

LOWER EXTREMITY CASTS:

Application of long leg cast

May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

Application of short leg cast

May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

SPLINTS:

Applications of long leg splint

Applications of short leg splint

May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, contractures or other deformities involving soft tissue.

STRAPPING:

Strapping of hip

May be indicated when there is involvement of the lower back, abdomen or hip in the treatment of contusions, dislocations, fractures, sprains/strains, post-op contusions, neuro-muscular conditions, contractures or other deformities involving soft tissue.

Strapping of knee

May be indicated when there is involvement of the lower leg, ankle and/or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op contusions, neuro-muscular conditions, contractures or other deformities involving soft tissue.

Strapping of ankle

May be indicated when there is involvement of the lower leg, ankle and/or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue.

Strapping of toes

May be indicated when there is involvement of any of the toes in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuro-muscular conditions, contractures or other deformities involving soft tissue.

Biofeedback Training by any Modality and Biofeedback Training, Perineal Muscles, anorectal or urethral sphincter, including electromyography (EMG) and/or manometry

The coverage criteria and definition of biofeedback is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §30.1 Biofeedback Therapy and §30.1.1 Biofeedback Therapy for the Treatment of Urinary Incontinence.

Evaluation of oral and pharyngeal swallowing function

The evaluation of oropharyngeal swallowing dysfunction including the phases of oral preparatory, oral/voluntary and pharyngeal in reference to oral and motility problems in the oral cavity and pharynx.

The clinical examination may include:

a) History of patient's disorder and awareness of swallowing disorder, and indications of localization and nature of disorder

b) Medical status including nutritional and respiratory status

c) Oral anatomy/physiology (labial control, lingual control, palatal function)

d) Pharyngeal function

e) Laryngeal function

The policy text continues in the CMS record.

Summary of evidence (opening)

N/A

the full summary and analysis of evidence are in the CMS record.

Dates, lineage and related policies

Original determination effective: 2015-10-01
Current revision effective: 2022-06-09
Last reviewed by the contractor: 2022-05-03
MCD version: 76
Derived from: L31530

The contractor lists 13 National Coverage Determinations as related: NCD 10.2 Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post-Operative Pain, NCD 150.8 Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders, NCD 160.12 Neuromuscular Electrical Stimulation (NMES), NCD 160.13 Supplies Used in the Delivery of Transcutaneous Electrical Nerve Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES), NCD 160.15 Electrotherapy for Treatment of Facial Nerve Paralysis (Bell's Palsy), NCD 160.27 Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP), NCD 160.7 Electrical Nerve Stimulators, NCD 170.1 Institutional and Home Care Patient Education Programs, NCD 240.3 Heat Treatment, Including the Use of Diathermy and Ultra-Sound for Pulmonary Conditions, NCD 270.1 Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds, NCD 270.6 Infrared Therapy Devices, NCD 30.1 Biofeedback Therapy, NCD 30.1.1 Biofeedback Therapy for the Treatment of Urinary Incontinence. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.

Using this policy on a claim

Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Palmetto GBA hub lists every other active policy from the same contractor.

Frequently asked questions

What does LCD L34560 cover?

Although rehabilitative services are provided by physical therapy (PT), speech therapy (ST) and occupational therapy (OT), this policy only addresses OT. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.

Which states does LCD L34560 apply to?

Palmetto GBA applies it to Medicare claims in AL, AR, FL, GA, IL, IN, KY, LA, MS, NC, NM, OH, OK, SC, TN, TX. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.

Which diagnosis codes support medical necessity under LCD L34560?

The companion billing and coding article A53057 lists 7,833 ICD-10-CM codes in 1 group that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.

How do I appeal a denial under LCD L34560?

The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.

Medicare Coverage Database, current LCD export
Version MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
Medicare Coverage Database, current Billing and Coding Articles export
Version MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
ICD-10-CM FY2027 code descriptions
Version FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…

Disclaimer

The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.

LCD L34560: Home Health Occupational Therapy