On October 20th, 2025, I sent a formal letter to the Evolent Health Clinical Policy and Review Division. It wasn’t a letter I wanted to write. It was one I had to.

Since switching to this third-party Prior Authorization agency, my small clinic has had numerous requests sitting in review, while cases with a confirmed history of stroke, an approved diagnostic variation, or an orthopedic surgery often receive automatic sessions. My patients, who are among the most underserved populations in my community, neurologically complex older adults with multiple underlying comorbidities, are reviewed one by one.

One gentleman, recovering from a bilateral brain injury, craniotomy, and multiple strokes, was denied continued care despite clear medical necessity and documented progress.

Because I am responsible for advocacy and for using my voice to support those in the healthcare system who cannot advocate for themselves, I needed to understand what was really happening. When I began investigating why, I realized the issue wasn’t my documentation or coding.

It was the policy itself.

The Problem Hidden in the Fine Print

Evolent Health’s Physical Medicine Guidelines are used to determine whether therapy sessions are “medically necessary.” These are the manuals clinical reviewers rely on when approving or denying care.

But here’s what I found after reading all 148 references across their 2025 series:

*These are approximated without decimal points

Across all four documents:

• Only 3 total references came from occupational therapy sources.

• The Occupational Therapy Practice Framework (OTPF-4) was cited once, and only to equate OT with “meaningful ADLs.”

• 0% addressed cognitive, psychosocial, or environmental rehabilitation, which are core to our profession.

That means 97% of the evidence informing coverage decisions for occupational therapy comes from other professions.

Why That Matters

Occupational therapy is not a subset of physical therapy.
It is its own discipline. The profession integrates neuroscience, psychology, and behavioral health with the functional goals of daily life.

When coverage policies are written almost entirely from a physical therapy perspective, patients who require cognitive, behavioral, or neuropsychological interventions are automatically disadvantaged.

If the only “evidence base” a reviewer sees is orthopedic or musculoskeletal, they’ll conclude that care focused on executive function, memory, or environmental adaptation isn’t “skilled.”

This is how systemic bias in evidence becomes a barrier to access.

A Bias Written Into Policy

To give a few examples:

• Neuromuscular re-education, one of the most critical codes for neurorehabilitation, is justified in Evolent’s guideline by three citations — one on premature infants, one from 1948, and one physical therapy paper on motor action observation.

• The guideline’s “home exercise program” expectation, which reviewers use to deny extended care, is supported by two orthopedic studies (low back pain and knee osteoarthritis). There is zero literature cited about cognitive or neurodegenerative conditions, or the impact of executive dysfunction on independent carryover.

This isn’t evidence-based practice; it’s professionally selective evidence that systematically favors one discipline over another.

The Letter I Sent

In my letter to Evolent, I formally requested the following actions:

1. Evidence Rebalance: Integrate AOTA, AJOT, and OTPF sources that reflect adult cognitive, psychosocial, and neurorehabilitation literature.

2. Reviewer Competency: Confirm that reviewers evaluating OT documentation are trained on OTPF-4 and the 2021 AOTA Scope of Practice.

3. Criterion Revision: Remove “independent exercise” assumptions for cognitively impaired or neurodegenerative populations.

4. Written Confirmation: Acknowledge the existing bias toward PT frameworks within current policy documentation.

I made clear that this is not about competition between professions. It’s about accurate representation of practice.

Occupational therapists don’t just teach ADLs.
We restore cognition, rebuild role identity, promote psychosocial resilience, and design environments where people can thrive.

That’s not “optional.”
That’s the core of our profession.

This is a link to the letter I wrote to advocate for the OT Profession.

Being Outspoken for the Right Reasons

When I created Outspoken OT, it wasn’t to stir controversy. It was to stand for truth in a profession that too often gets drowned out by louder voices.

Being outspoken doesn’t mean being combative.
It means advocating with evidence when silence perpetuates harm.

Policies like these don’t just affect clinicians; they shape who gets care, who doesn’t, and what kind of recovery is even possible.

When documentation standards erase occupational therapy’s full scope, patients lose access to the very interventions that can preserve independence and dignity.

What's Next: I will await their response and post an update on this blog.