2. Coverage criteria

Occupational therapy furnished by a participating hospital or by others under arrangements with the hospital and under its supervision is reimbursable when all the following conditions are met:

a. The services are prescribed by a physician;

b. The services are performed by a qualified occupational therapist or a qualified occupational therapy assistant under the general supervision of a qualified occupational therapist. (“General supervision” requires initial direction and periodic inspection of the actual activity; however, the supervisor need not always be physically present or on the premises when the assistant is performing services.);

c. The services are reasonable and necessary for the treatment of the individual's illness or injury. The guidelines in A.2. on an individual's restoration potential also apply to occupational therapy. Generally speaking, occupational therapy is not reasonable or necessary when a patient suffers a temporary loss or reduction of function which could be expected to spontaneously improve as the patient gradually resumes normal activities. Occupational therapy is also not usually considered reasonable and necessary in meeting motivational needs which are not related to a specific diagnosed psychiatric illness. As indicated in C.1, item g, occupational therapy includes vocational and prevocational assessment and training. When services provided by an occupational therapist and/or assistant are related solely to specific employment opportunities, work skills or work settings, they are not reasonable or necessary for the diagnosis or treatment of an illness or injury and are excluded from coverage.