Payment Notice: Cigna Site of Care Policy (Effective Date: 10/01/2025)
Cigna has announced a new Site of Care Policy effective 10/01/2025. This policy affects outpatient physical and occupational therapy services.
What is a Site of Care or Site of Service Policy?
Payers are always looking for the most cost-effective treatment for the services they cover. But they are also looking for the most cost-effective location for these services. Services that have been affected by site of care/service policies include advanced imaging, drug infusions, and outpatient surgeries. If a site or patient meets certain criteria, it is considered medically necessary for a service to be performed in a hospital outpatient department (HOPD). If these criteria are not met, the service must be performed in a freestanding facility.
Cigna has developed a Site of Care policy for physical and occupational therapy that restricts patients from being seen in a HOPD unless certain criteria are met.
What Places of Service (POS) are affected by this policy?
Place of Service (POS) codes designate the care setting on claims.
- POS 19: Off Campus-Outpatient Hospital
- POS 22: On Campus-Outpatient Hospital
POS code designating a freestanding clinic (not affected by this policy):
- POS 11: Office
What criteria must be met for patients to be seen in an HOPD?
Site Criteria:
- Specialized equipment (e.g., overhead harness system for gait training, exoskeleton for gait) is required for medically necessary PT/OT services not available in a freestanding PT/OT facility.
- Specialized PT/OT personnel (e.g., Board Certified Cardiovascular and Pulmonary Clinical Specialist, wound care certified) who are not available in a freestanding PT/OT facility are required to provide medically necessary services.
- A freestanding PT/OT facility is not available within a reasonable geographical location/distance.
Medical Criteria:
- Amputation within the last 12 months (i.e., Symes, transtibial, knee disarticulation, transfemoral, hip disarticulation, transradial, transhumeral, shoulder disarticulation)
- Severe burn injuries requiring debridement and frequent dressing changes
- Major organ transplant surgery (i.e., heart, lung, liver, kidney) within the last three months
- History of cardiovascular diagnoses that would increase risk and/or would require ongoing higher acuity monitoring (e.g., telemetry, ECG) during therapy including but not limited to:
- Aortic stenosis
- Cardiomyopathy
- Implanted cardioverter-defibrillator
- Implanted pacemaker
- Myocardial infarction (MI) within past three months
- Recent coronary intervention (i.e., plain angioplasty within 90 days, bare metal stents placed within 90 days, drug eluting stents placed within one year)
- Severe/significant valvular disease
- Stage 3 hypertension (HTN) (e.g., BP > 180/110)
- Symptomatic/unstable cardiac arrhythmia
- Unstable coronary syndromes (i.e., unstable or severe angina [Canadian Class III or IV], uncompensated chronic heart failure [CHF] [NYHA class III or IV])
- History of neurological diagnoses that would increase risk and/or would require ongoing higher acuity monitoring (e.g., telemetry, ECG) during therapy including but not limited to:
- Cerebellar ataxias
- Corticobasal degeneration
- Dysautonomia with blood pressure and heart rate instability
- History of a cerebrovascular accident (CVA) within the last three months
- Multisystem atrophy
- Normal pressure hydrocephalus (NPH)
- Parkinson’s disease
- Progressive motor neuron disease (e.g., spinal muscular atrophy, amyotrophic lateral sclerosis, primary lateral sclerosis)
- Progressive supranuclear palsy
- Severe traumatic brain injury within the last three months
- Spinal cord injury (e.g., paralysis, central cord syndrome) within last 12 months
How can a hospital determine whether a patient can be seen at their facility?
- A Site of Care Portal will be available on 10/01/2025
Other Resources:
- Cigna Site of Care Policy
- Cigna/American Specialty Health Training (Recordings will be available on 09/15/2025)
If you have any further questions on this Site of Care Policy, you may call American Specialty Health at 1-833-695-1781 or reach out to APTA Wisconsin at aptawi@aptawi.org.
