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Outpatient Physical Medicine, Rehabilitation, and Habilitation Services
10.03.01o

Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

Physical medicine and rehabilitative services include physical therapy (PT), occupational therapy (OT), evaluation and management (E&M), tests and measurements, and therapeutic procedures. They are considered eligible for reimbursement by the Company when all of the following criteria are met:
  • The service is used to treat an illness or injury and to promote recovery by providing specific, effective, and reasonable treatment for the individual's diagnosis and physical condition.
  • The service is prescribed by a physician or other qualified professional provider.
  • The service must be rendered by or under the direction of a professional provider who is appropriately licensed to perform the service and who is eligible under the terms of the benefit contract.
Benefits for all services related to outpatient PT/OT are provided to individuals in accordance with the benefit contract and any applicable state mandates, and vary by product and group. Individual member benefits must be verified for specific coverage criteria regarding limits, existing contractual exclusions, and specific state mandate coverage criteria.

PHYSICAL AND OCCUPATIONAL THERAPY EVALUATION

MEDICALLY NECESSARY
PT and/or OT evaluation is medically necessary and, therefore, covered for professional providers to determine required, appropriate services to improve, maintain, or slow deterioration of the individual’s current condition.

Impairments, functional limitations, and disabilities identified via clinical history, physical examination, and other evaluations are then addressed by a plan of care tailored to the specific needs of the individual. Interventions are applied or modified based on diagnosis, prognosis, and anticipated goals.

During the initial encounter, the professional provider evaluates and documents all of the following:
  • A diagnosis and description of the specific problem(s) to be evaluated and/or treated.
    • The diagnosis must be specific and as relevant to the problem to be treated as possible, including the body part evaluated, and all conditions and complexities that may impact the treatment.
  • Objective measurements including standardized individual assessment instruments and/or outcomes measurement tools related to current physical and functional status, when these are available and appropriate to the condition being evaluated.
    • The medical record must document the following as applicable:
      • Severity or complexity of the illness
      • The individual’s general health
      • The individual’s home environment
  • Professional provider’s clinical judgments or subjective impressions that describe the current functional status of the condition being evaluated, when they provide further information to supplement measurement tools.
  • A determination that treatment is not needed, or, if treatment is needed, a prognosis for return to premorbid condition or maximum expected condition with expected time frame and a plan of care.
  • A written plan of care, consisting of diagnoses, long-term treatment goals and type, amount, duration, and frequency of therapy services, must be established by the professional provider rendering the services before the services are begun. The written plan of care must also have the following:
    • Initial approval by the professional provider
    • Periodic review by the professional provider
      • The assessment of the individual's progress in meeting the objectives of the plan of care must be reviewed every 90 calendar days.
      • New or significantly modified plans of care must be approved within 30 calendar days after the initial treatment.
Although an individual's particular medical condition is a valid factor in deciding if skilled therapy services are needed, an individual's diagnosis or prognosis cannot be the sole factor in deciding that a service is skilled or not skilled. The key issue is whether the skills of a physical therapist and/or occupational therapist are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel or caregivers.

NOT MEDICALLY NECESSARY
The following PT and/or OT services are considered not medically necessary and, therefore, not covered:
  • Services that do not require the professional skills of a qualified physical or occupational therapist to perform or supervise
  • Services not relating to a written plan of care
  • Services that do not require the professional skills of a professional provider to perform or supervise
PHYSICAL AND OCCUPATIONAL THERAPY RE-EVALUATION

MEDICALLY NECESSARY
A PT and/or OT re-evaluation is considered medically necessary and, therefore, covered during an episode of care when a significant improvement, decline, or change in the individual's condition occurs. A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment, or terminating services. Re-evaluation requires the same professional skills as evaluation. It is not a routine, recurring service. Indications for a re-evaluation include the following:
  • New clinical findings
  • Significant change in the individual's condition
  • Failure to respond to the therapeutic interventions outlined in the plan of care
Continuous assessment of the individual's progress is a component of ongoing therapy services and is not a re-evaluation.

The key issue remains whether the skills of a PT and/or OT are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel or caregivers.

NOT MEDICALLY NECESSARY
The following PT and/or OT services are considered not medically necessary and, therefore, not covered:
  • Services that do not require the professional skills of a qualified physical or occupational therapist to perform or supervise
  • Services not relating to a written plan of care
  • Services that do not require the professional skills of a professional provider to perform or supervise
DISCONTINUATION OF PHYSICAL AND/OR OCCUPATIONAL THERAPY SERVICES

The continuation of PT and/or OT services are considered not medically necessary and, therefore, not covered if it is determined that an individual has attained the established therapy goals or has reached the point where no further significant progress can be expected upon evaluation of the plan of care as evidenced by standardized objective measurements (e.g., Patient Inquiry by Focus on Therapeutic Outcomes, Inc. [FOTO]; Activity Measure-Post Acute Care [AM-PAC]; OPTIMAL by Cedaron through the American Physical Therapy Association) because the available published peer-reviewed literature does not support its use in the treatment of illness or injury.

PHYSICAL MEDICINE AND REHABILITATIVE (PMR) MODALITIES

MEDICALLY NECESSARY
The use of PMR modalities is medically necessary and, therefore, covered in many clinical situations as indicated below. Documentation in the individual’s medical record must support the use of the PMR modalities and include the following:
  • An assessment by a professional provider supporting utilization of the PMR modality
  • Objective physical and functional limitations (signs and symptoms)
  • A written plan of care incorporating those treatment elements that require services of a skilled therapist for a reasonable and generally predictable period of time
  • Clinical justification for the use and continued use of PMR modalities
  • Clinical justification for multiple PMR modalities on the same day
  • Use of modalities as contributing to the individual’s progress and restoration of function
The use of modalities must either require supervision by a qualified professional provider or one-to-one interaction with the individual by a qualified professional provider.

SUPERVISED MODALITIES
Supervised modalities are considered to be the application of a modality that does not require direct (one-on-one) individual contact by the provider. There is no time component that describes supervised codes. The code is reported without regard to the length of time spent performing the service. These services are to be billed only once per encounter regardless of the number of areas treated.

Hot or Cold Packs

Not Eligible for Separate Reimbursement
Hot or cold packs are used primarily in conjunction with therapeutic procedures to provide analgesia, relieve muscle spasm, and reduce inflammation and edema. Typically, cold packs are used for acute, painful conditions, and hot packs are used for subacute or chronic painful conditions.

Heat or cold treatments ordinarily do not require the skills of a qualified clinician. The skills, knowledge, and judgment of a qualified clinician may be required while considering and applying these services in cases where a potential contraindication and/or precaution to the treatment exists.

The application of hot or cold packs when performed alone or in conjunction with another procedure is not eligible for separate reimbursement because it is considered part of the physical medicine and rehabilitation services.

Mechanical Traction Therapy

Medically Necessary
Mechanical traction is the force used to create a degree of tension on soft tissues and/or allow for separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds) allowed, duration (time), and angle of pull (degrees) using mechanical means. Terms often used in describing pelvic/cervical traction are intermittent or static (describing the length of time traction is applied) or autotraction (use of the body’s own weight to create the force). Mechanical traction is used for the cervical and lumbar spine to relieve pain in or originating from those areas.

Mechanical traction therapy is considered medically necessary and, therefore, covered for specific indications including cervical and/or lumbar radiculopathy and back disorders such as disk herniation, lumbago, and sciatica.

Unattended Electrical Stimulation

Medically Necessary
Unattended electrical stimulation used in conjunction with medically necessary therapeutic exercise for indications other than wound care is considered medically necessary and, therefore, covered for any of the following conditions:
  • When performed as an integral part of the treatment elements as documented in the plan of care
  • To facilitate reduction of pain, edema, and muscle spasm
  • Increase contractile force in muscles
This modality will be used in a clearly adjunctive role and not as a major component of the therapeutic encounter when used for muscle strengthening or retraining. The nerve supply to the muscle must be intact.

Not Medically Necessary
Unattended electrical stimulation for completely denervated motor nerve disorders in which there is no potential for recovery or restoration of function is considered not medically necessary and, therefore, not covered.

Vasopneumatic Devices

Medically Necessary
The use of vasopneumatic devices is considered medically necessary and, therefore, covered for the application of pressure to an extremity in order to reduce edema or lymphedema. Specific indications for the use of vasopneumatic devices include the reduction of edema after acute injury and the treatment of lymphedema of an extremity.

When treating lymphedema with this device, the sessions are for the primary purpose of determining the individual response to treatment, and, if indicated, to teach the individual how to use the lymphedema pump at home.

Paraffin Bath Therapy

Medically Necessary
Paraffin bath therapy, also known as hot wax treatment, is considered medically necessary and, therefore, covered when primarily used for pain relief in chronic joint problems of the wrists, hands, or feet.

Paraffin bath therapy is used to apply superficial heat for a sustained duration for the effects on underlying tissues. Paraffin is contraindicated for open wounds or areas with documented desensitization.

Whirlpool Therapy

Medically Necessary
Whirlpool therapy, the use of agitated water, is considered medically necessary and, therefore, covered to relieve muscle spasms, improve circulation, and promote the healing of wounds.

Not Medically Necessary
More than one form of hydrotherapy during a visit (i.e., whirlpool, Hubbard tank, aquatic therapy with therapeutic exercises) is considered not medically necessary and, therefore, not covered.

Dry Hydrotherapy


Experimental/Investigational

Dry hydrotherapy (e.g. AquaMED, Sidmar), also called hydromassage, aquamassage, and water massage, uses heated water in a self-contained device such as a table or chair that circulates around the individual in a massaging or pulsing manner for relief of pain, increase of blood circulation, and range of motion (ROM), is considered experimental/investigational and, therefore, not covered because there is insufficient scientific evidence on the effectiveness of this service.​


Diathermy Treatment

Medically Necessary
Diathermy is a modality for heating skeletal muscle. The use of diathermy is considered medically necessary and, therefore, covered for the delivery of heat to deep tissues such as skeletal muscle and joints for the reduction of pain, joint stiffness, and muscle spasm. The specific indications for the use of diathermy include any of the following:
  • Osteoarthritis, rheumatoid arthritis, or traumatic arthritis
  • Sustained sprain or strain
  • Acute or chronic bursitis
  • Traumatic injury to muscle, ligament, or tendon resulting in functional loss
  • Joint dislocation or subluxation
  • Postsurgical functional loss
  • Adhesive capsulitis
  • Joint contracture
High-energy, pulsed wave diathermy machines have been determined to produce the same therapeutic benefit as standard diathermy; thus, these treatments are considered medically necessary and, therefore, covered for the same indications as standard diathermy.

Not Medically Necessary
Diathermy is not medically necessary and, therefore, not covered for the treatment of asthma, bronchitis, or any other pulmonary condition.

Infrared Therapy

Experimental/Investigational
Infrared and/or near-infrared light and/or heat therapy including monochromatic infrared energy (MIRE) in the treatment of symptoms such as pain arising from the conditions of diabetic and/or nondiabetic peripheral sensory neuropathy, wounds, and/or skin ulcers is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by a review of the available published peer reviewed literature.

Ultraviolet therapy

Medically Necessary
Ultraviolet therapy is a form of radiant energy that uses light rays with wavelengths beyond the violet end of the visual spectrum to stimulate a variety of chemical reactions in the skin and mucous membranes, increasing vascularization to the margins of wounds. The application of ultraviolet therapy is considered medically necessary and, therefore, covered for individuals requiring the application of a drying heat for the treatment of an open wound and severe psoriasis limiting range of motion.

CONSTANT ATTENDANCE MODALITIES
Constant attendance modalities are considered to be the application of a modality that requires direct (one-on-one) individual contact by the provider. Direct one-on-one contact requires that the provider maintain visual, verbal, and/or manual contact with the individual throughout the procedure. The time frames indicated for the constant attendance modalities describe the total time (pre-service, intra-service, and post-service time) spent performing this modality.

Attended Electrical Stimulation

Medically Necessary
Attended electrical stimulation is considered medically necessary and, therefore, covered when used in the treatment of conditions that include, but are not limited to, muscle atrophy and ambulation in individuals with spinal cord injury.

Documentation must include all of the following:
  • Type of electrical stimulation used
  • Area being treated
  • If used for muscle weakness, objective rating of strength, and functional deficits
  • If used for pain, pain rating, location of the pain, effect of pain on function
For individuals with disuse atrophy, attended electrical stimulation is limited to individuals in whom the nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves.

Experimental/Investigational
Attended electrical stimulation is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by a review of the available published peer-reviewed literature, when used in the treatment of the following conditions:
  • Facial nerve paralysis
  • Motor function disorders (e.g., multiple sclerosis)
Not Medically Necessary
Attended electrical stimulation when used alone, solely for strengthening muscle, is considered not medically necessary and, therefore, not covered.

Iontophoresis

Medically Necessary
Iontophoresis is a process in which electrically charged molecules or atoms of a chosen medication are driven into the tissue with an electrical field. Voltage provides the driving force.

Iontophoresis is considered medically necessary and, therefore, covered for the delivery of medications into a specific area of the body to reduce pain (e.g., local anesthetic agents) and for the treatment of primary hyperhidrosis.

Not Medically Necessary
Iontophoretic delivery of nonsteroidal anti-inflammatory drugs (NSAIDS) or corticosteroids is considered not medically necessary and, therefore, not covered because the available published peer reviewed literature does not support its use in the treatment of musculoskeletal disorders.

Contrast Baths

Medically Necessary
Contrast bath therapy is the alternate immersion of a body part in hot water and cold water. This special form of therapeutic heat and cold is commonly applied to distal extremities.

Contrast baths are considered medically necessary and, therefore, covered for the treatment of conditions that include but are not limited to rheumatoid arthritis, other inflammatory arthritis, reflex sympathetic dystrophy, or a sprain or strain resulting from an acute injury.

Low-Level Laser Therapy (LLLT)

Experimental/Investigational
Low-level laser therapy (LLLT), also referred to as Photobiomodulation Therapy, is considered experimental/investigational and, therefore, not covered, because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature. ​​

Ultrasound

Medically Necessary
Therapeutic ultrasound is a deep heat modality. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone can receive an even greater dosage of ultrasound—as much as 30 percent more. Because of the increased extensibility that ultrasound produces in tissues of high collagen content, combined with the close proximity of joint capsules, tendons, and ligaments to cortical bone where they receive a more intense heating, therapeutic ultrasound is an ideal modality for increasing mobility in those tissues with restricted range of motion.

The application of ultrasound is considered medically necessary and, therefore, covered for individuals requiring deep heat to a specific area for reduction of pain, spasm, and joint stiffness, and to increase the flexibility of muscles, tendons, and ligaments.

Specific indications for the use of ultrasound application include, but are not limited to, the individual having neuromas, symptomatic soft tissue calcification, or tightened structures limiting joint motion that require an increase in extensibility.

Not Medically Necessary
Ultrasound application is considered not medically necessary and, therefore, not covered for the treatment of asthma, bronchitis, or any other pulmonary condition.

Hubbard Tank

Medically Necessary
This modality involves the individual’s immersion in a full-body tank of agitated water to relieve muscle spasm, to improve circulation, and to cleanse wounds, ulcers, or exfoliative skin conditions. Hubbard tank therapy is considered medically necessary and, therefore, covered when the therapy is conducted with one-on-one supervision by a qualified professional. Documentation in the medical record must clearly note that the skills of a qualified professional were necessary in order to treat the individual with this modality.

Not Medically Necessary
More than one form of hydrotherapy during a visit (i.e., whirlpool, Hubbard tank, aquatic therapy with therapeutic exercises) is considered not medically necessary and, therefore, not covered.

THERAPEUTIC PROCEDURES

Therapeutic procedures are treatments that attempt to reduce impairments and improve, restore, maintain, and/or compensate for loss of function through the application of clinical skills and/or services. Use of these procedures requires that the qualified professional have direct (one-on-one) individual contact. Therapeutic exercises, neuromuscular re-education, aquatic therapy/exercises, and therapeutic activities are examples of several different types of therapeutic procedures. There may be one or any combination of more than one therapeutic procedure used in the plan of care.

The use of therapeutic procedures are medically necessary and, therefore, covered in many clinical situations as indicated below. Documentation must support the use of each treatment as it relates to the specific therapeutic goal.

THERAPEUTIC EXERCISE

Medically Necessary

Therapeutic exercise is designed to develop strength and endurance, range of motion, and flexibility, and may include active, active-assisted, or passive exercises. Therapeutic exercise is considered medically necessary and, therefore, covered for a loss or restriction of joint motion, strength, functional capacity, or mobility that has resulted from a specific disease or injury.

Documentation must include objective findings related to joint motion, strength, or mobility impairments (e.g., degrees of motion, strength grades, levels of assistance) in addition to any of the following to support medical necessity of therapeutic exercise.

In addition, the goals of therapeutic exercise are to improve mobility, stretching, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance as part of activities of daily living training or re-education.

Not Medically Necessary

The following therapeutic exercises are considered not medically necessary and, therefore, not covered:
  • Repetitive exercises to promote overall fitness, flexibility, endurance enhancement, aerobic conditioning, weight reduction, and maintenance exercises to maintain range of motion and/or strength
  • Passive exercises not related to restoring specific loss of function
NEUROMUSCULAR RE-EDUCATION

Medically Necessary

Neuromuscular re-education provides improvement of balance, coordination, kinesthetic sense, posture, and proprioception. Examples of these treatments include proprioceptive neuromuscular facilitation (PNF), Feldenkreis, Bobath, biomechanical ankle platform system (BAPS) boards, and desensitization techniques.

Neuromuscular re-education is considered medically necessary and, therefore, covered for the following documented impairments that affect the body's neuromuscular system:
  • Loss of deep tendon reflexes and vibration sense accompanied by paresthesia, burning, or diffuse pain of the feet, lower legs, and/or fingers
  • Nerve palsy, such as peroneal nerve injury causing foot drop
  • Muscular weakness or flaccidity as result of a cerebral dysfunction, a nerve injury or disease, or having had a spinal cord disease or trauma
  • Poor static or dynamic sitting/standing balance
  • Loss of gross and fine motor coordination
  • Hypo/hypertonicity
AQUATIC THERAPY WITH THERAPEUTIC EXERCISES

Medically Necessary

Aquatic therapy with therapeutic exercise uses buoyancy and the resistance properties of water and is considered medically necessary and, therefore, covered for any of the following indications:
  • Loss or restriction of joint motion, strength, mobility, or function, which has resulted from a specific disease or injury
  • The individual cannot perform land-based exercise effectively to treat their condition without first undergoing aquatic therapy.
Documentation must include objective findings related to joint motion, strength, or mobility impairments (e.g., degrees of motion, strength grades, levels of assistance) and reflect the medical necessity of the treatment in a water environment. Other forms of exercise therapy may be medically necessary in addition to aquatic therapy.

Not Medically Necessary

Repetitive exercises in the water environment to promote overall fitness, flexibility, endurance enhancement, aerobic conditioning, weight reduction, or for maintenance purposes are considered not medically necessary and, therefore, are not covered.

GAIT TRAINING

Medically Necessary

Gait training is the training of the biomechanical and kinesiological components of walking, including balance, cadence, symmetry, motor control, speed, and energy efficiency and is used to improve, restore, maintain, and/or compensate for impairment of walking ability due to neurological, muscular, or skeletal abnormalities or trauma. Gait training is considered medically necessary and, therefore, covered for indications including, but not limited to, the following:
  • Cerebral vascular accident resulting in impairment in the ability to ambulate
  • Musculoskeletal trauma requiring ambulation re-education
  • Chronic, progressively debilitating conditions for which safe ambulation has recently become a concern
  • Injuries or conditions that require instruction in the use of an assistive device (e.g., walker, crutches, cane)
  • Instruction required in ambulation for an individual who has been fitted with a brace/lower limb prosthesis
  • Condition that requires training in stairs/steps or chair transfers in addition to general ambulation
Not Medically Necessary

Gait training therapy in conjunction with orthotic management training is considered not medically necessary and, therefore, not covered, with the following exception:
  • Orthotic management and training performed on an upper extremity in conjunction with gait training
MASSAGE

Benefit Contract Exclusion

Massage therapy, a complementary and integrative health service (alternative therapy and complementary medicine), is considered a benefit contract exclusion for most Company products and groups with the following exception:
  • Therapeutic massage, as a medically prescribed treatment for physical disabilities or impairments resulting from disease, injury, or congenital anomaly, is a covered service when provided by an eligible professional provider who is defined as such in the respective benefit contracts.
    • Although various assistive devices (e.g., massage chair) and electrical equipment are available in delivering massage, use of the hands is considered the most effective method of application; therefore, massage performed with devices, electrical equipment, and/or as an isolated treatment is not covered.
MANUAL THERAPY TECHNIQUES

Medically Necessary

Manual therapy techniques described as "hands-on therapy techniques" consist of manual traction, joint mobilization and manipulation, soft tissue mobilization, and manual lymphatic drainage. The use of manual therapy techniques is medically necessary and, therefore, covered in clinical situations as indicated below. The goals of manual therapy are to modulate pain, increase joint range of motion, and reduce or eliminate soft tissue swelling, inflammation, or restriction. These techniques also induce relaxation and improve contractile and noncontractile tissue extensibility.

Manual Traction
Manual traction is considered medically necessary and, therefore, covered for cervical radiculopathy and cervicalgia.

Joint Mobilization
Joint mobilization (peripheral or spinal) is considered medically necessary and, therefore, covered if restricted joint motion is documented as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.

Soft Tissue Mobilization
Soft tissue mobilization is the use of skilled manual therapy techniques (active or passive) applied to effect changes in the soft tissues, articular structures, and neural or vascular systems by the facilitation of fluid exchange, restoration of movement in acutely edematous muscles, and the stretching of shortened muscular scar or connective tissue. Soft tissue mobilization is considered medically necessary and, therefore, covered for treatment of restricted motion of soft tissues involving the extremities, neck, or trunk.

Manual Lymphatic Drainage
Manual lymphatic drainage, a manual technique utilized to facilitate the movement of excessive lymphatic fluid, is considered medically necessary and, therefore, covered for treatment of painful spasm or restricted motion of soft tissues.

Refer to the policy titled Complete Decongestive Therapy (CDT), 07.06.01b, for information about the comprehensive lymphedema management program.

MANIPULATION

Medically Necessary

Manipulation of the Rib Cage
Manual manipulation of the rib cage contributes to the treatment of respiratory conditions such as bronchitis, emphysema, and asthma as part of a regimen that includes other elements of therapy, and is covered only under such circumstances.

Manipulation of the Head
Manipulation of the occipitocervical or temporomandibular regions of the head when indicated for conditions affecting those portions of the head and neck is a covered service.

GROUP THERAPEUTIC PROCEDURES

Medically Necessary

Group therapy is considered medically necessary and, therefore, covered when the provided services are appropriate to each individual's plan of care. Therefore, group therapy sessions (two or more individuals) should be of sufficient length to address the needs of each of the individuals in the group. Although group therapy services are included with the therapeutic procedures that require one-on-one individual contact, these services involve constant attendance of the qualified healthcare professional, but by definition do not require one-on-one individual contact by the same healthcare professional.

Documentation must identify the specific treatment technique(s) used in the group, how the treatment technique will restore function, the frequency and duration of the particular group setting, and the treatment goal in the individualized (individual-specific) plan. The number of persons in the group must also be documented. These records must be made available to the company upon request.

THERAPEUTIC ACTIVITIES

MEDICALLY NECESSARY

Therapeutic activities involve the use of functional activities (e.g., bending, lifting, carrying, reaching, catching, overhead activities, and performance of transitional movements or activities) to improve, restore, and/or compensate for loss of functional performance, including, where applicable, performance of transitional movements, in a progressive manner.

Therapeutic activities are considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The individual has a documented condition for which therapeutic activities can reasonably be expected to restore or improve functioning.
  • There is a clear correlation between the type of exercise performed and the individual's underlying medical condition for which the therapeutic activities were prescribed.
  • The individual is unable to perform the therapeutic activities without the skilled intervention of the professional provider.
COGNITIVE REHABILITATION

BENEFIT CONTRACT EXCLUSION

Cognitive rehabilitation therapy is a benefit contract exclusion and is, therefore, not covered, with the following exception: when it is integral to other supportive therapies, such as, but not limited to, physical and occupational therapies in a multidisciplinary, goal-oriented, and integrated treatment program designed to improve management and independence following neurological damage to the central nervous system caused by illness or trauma (e.g., stroke, acute brain insult, encephalopathy).

SENSORY INTEGRATIVE TECHNIQUES

MEDICALLY NECESSARY

Sensory integrative techniques are considered medically necessary and, therefore, covered when the treatment is used to enhance sensory processing and to promote adaptive responses to environmental demands with direct (one-on-one) individual contact by the professional provider. When an individual has a deficit in processing input from a sensory system (e.g., vestibular, proprioceptive, tactile), it may decrease the individual’s ability to make adaptive sensory, motor, and behavioral responses to environmental demands. An example is an individual with several oral deficits secondary to a stroke.

SELF-CARE/HOME MANAGEMENT TRAINING

MEDICALLY NECESSARY

Self-care/home management training includes activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment, and requires direct one-on-one contact by the qualified professional. This procedure is medically necessary and, therefore, covered only when it requires the skills of a qualified professional provider, is designed to address specific needs of the individual, and is part of an active plan of care directed at a specific outcome. Documentation must relate the training to expected functional goals that are attainable by the individual, and such training must be reasonably expected to improve, restore, maintain, and/or compensate for loss of functioning of the individual. The individual and/or caregiver must have the capacity to learn from instructions.

Services provided by qualified health care providers of different types (e.g., physical therapists, occupational therapists) may be covered if separate and distinct goals are documented in the separate plans of care.

COMMUNITY/WORK REINTEGRATION TRAINING

MEDICALLY NECESSARY

Community/work reintegration training includes shopping, transportation, money management, a vocational activities and/or work environment/modification analysis, work task analysis, and direct one-on-one contact by the provider.

Community reintegration procedures are considered medically necessary and, therefore, covered when they require the specific skills of a qualified professional provider, are designed to address specific needs of the individual, and are part of an active plan of care directed at a specific outcome. The plan of care may be aimed at improving, restoring, maintaining, and/or compensating for loss of specific functions that were impaired by an identified illness or injury, and when the expected outcomes, that are attainable by the individual, are specified in the plan of care.

NOT MEDICALLY NECESSARY

General activity programs and all activities that are primarily social or diversional in nature, are considered not medically necessary and, therefore, not covered because the professional skills of a qualified professional provider are not required.

WHEELCHAIR MANAGEMENT

MEDICALLY NECESSARY

Wheelchair management includes assessment of the need for a wheelchair, determination of the type of wheelchair and wheelchair components, measuring for and fitting the wheelchair, making adjustments, and training in the use of the chair. This service includes training the individual in functional activities that promote optimal safety, mobility, and transfers. Individuals who are wheelchair bound may occasionally need skilled input on positioning, positioning supplies, and wheel chair modifications to avoid pressure points, contractures, and other medical complications. The individual and/or caregiver must have the capacity to learn from instructions.

Wheelchair management is considered medically necessary and, therefore, covered when it requires the skills of a qualified professional, is designed to address specific mobility needs of the individual, and is part of an active plan of care directed toward the individual's independence and ability to assist with transfers and aspects of mobility.

WORK HARDENING/CONDITIONING

BENEFIT CONTRACT EXCLUSION

Work hardening/conditioning services relate solely to specific employment opportunities, work skills, or work settings and are considered not medically necessary for the diagnosis and treatment of an illness or injury and are, therefore, not covered.

TESTS AND MEASUREMENTS

PHYSICAL PERFORMANCE TEST OR MEASUREMENT

Medically Necessary

Physical performance test or measurement is used to quantify muscle strength and an individual’s response to rehabilitation and therapy. These tests include isokinetic tests also known as quantitative muscle tests and the Tinetti assessment tool. The isokinetic test/quantitative muscle test is a comparison of the involved and uninvolved extremities, and the Tinetti assessment tool measures an individual’s gait and balance.

A physical performance test or measurement is medically necessary and, therefore, covered for individuals with neurological or musculoskeletal conditions when such a test and measurement is needed to formulate and/or evaluate a specific treatment plan or determine an individual’s capacity.

The individual’s medical record must include the following documentation to support the request for physical performance test or measurement:
  • The condition requiring the test
  • The specific test performed
  • A measurement report
  • Impact to the plan of care
Not Medically Necessary

Although the US Food and Drug Administration (FDA) has approved devices (e.g., Biodex, Cybex) for isokinetic muscle tests/quantitative muscle tests, the Company has determined that the available published peer-reviewed literature does not support the service as a useful aid in the diagnosis of illness or injury. Therefore, isokinetic muscle testing with an isokinetic dynamometer is considered not medically necessary by the Company and not covered.

A physical performance test and measurement is considered not medically necessary and, therefore, not covered when the test is performed on a routine basis (i.e., monthly), in place of a re-evaluation or on all individuals routinely being treated.

ASSISTIVE TECHNOLOGY ASSESSMENT

Medically Necessary

Assistive technology assessment involves the provider’s assessment of the need for a technological interface between the individual and their environment or mobility system. The individual’s voluntary motions (e.g., oral motor strength, head/neck range of motion and strength, ocular motor control, quality of voice output) are identified and assessed. Multiple systems/components are tested to determine optimal interface between individual and technology applications.

Assistive technology assessment is considered medically necessary and, therefore, covered when the following criteria are met: the professional provider furnishes one-on-one direct contact for each 15 minutes of assessment. (This service is not eligible for coverage if provided by a PT or OT assistant.) In addition, the individual's medical record must clearly contain the provider’s written report of the assessment and must include all of the following:
  • The goal of the assessment
  • The technology/component/system involved
  • A description of the process involved in assessing the individual’s response
  • The outcome of the assessment
  • Documentation of how this information affects the plan of care
ORTHOTIC MANAGEMENT AND PROSTHETIC MANAGEMENT

ORTHOTIC MANAGEMENT AND TRAINING

Medically Necessary

Orthotic management and training is medically necessary and, therefore, covered to promote an indicated immobilization, and/or to assist the individual to function at a higher level by decreasing functional limitations or the risk of further functional limitations.

Documentation for orthotic management and training must include the following:
  • A description of the individual’s condition, including applicable impairments and functional limitations that necessitate an orthotic device
  • Any complicating factors
  • The specific orthotic provided and the date issued
  • A description of the skilled training provided in the use and care of the orthotic
  • Response of the individual to the orthotic
Not Medically Necessary

Gait training therapy in conjunction with orthotic management training is not medically necessary and, therefore, not covered. An exception to this would be if orthotic management and training was performed on an upper extremity in conjunction with gait training.

Orthotic management and training is considered not medically necessary and, therefore, not covered for prefabricated/commercial (i.e., off the shelf) components such as, but not limited to, a lumbar roll, noncustomized foam supports/wedges (i.e., heel cushions) or Multi Podus boots.

When the management of the orthotic can be turned over to the individual, the caregiver, or nursing staff, the services of the therapist are considered not medically necessary and, therefore, not covered.

PROSTHETIC TRAINING

Medically Necessary

Prosthetic training is the professional instruction necessary for an individual to properly use an artificial device that has been developed to replace a missing body part. Prosthetic training is considered medically necessary and therefore covered if there is an indication for education on the application of the prosthesis, and/or use of the prosthesis, in all applicable environments.

The medical record must include documentation of the distinct goals and service rendered when prosthetic training for a lower extremity is done during the same visit as gait training or self-care/home management training. Periodic revisits beyond the third month would require documentation to support medical necessity of this training.

CHECKOUT FOR ORTHOTIC/PROSTHETIC USE

Medically Necessary

Orthotic/prosthetic checkout is an end-service for an established individual that is used to report the time spent to ensure a correct fit when using the orthotic or prosthetic during functional activities. An example of this is checking for skin integrity where the orthotic/prosthetic device may apply pressure. Any adjustments or repairs may be made to ensure alignment, and reinstruction may be required.

Orthotic/prosthetic checkout is considered medically necessary and, therefore, covered for the following:
  • Modification or reissue of a device
  • Reassessment of a newly issued device
  • When an individual experiences a loss or change in function directly related to the device (e.g., pain, skin breakdown, or change in edema)
Documentation in the medical record should support the medical necessity of the orthotic/prosthetic checkout.

ATHLETIC TRAINING

BENEFIT CONTRACT EXCLUSION

Athletic training services are not covered because they are benefit contract exclusions. Therefore, they are not eligible for reimbursement consideration.

VISION REHABILITATION

MEDICALLY NECESSARY

Visual impairments ranging from low vision to total blindness may result from a primary eye diagnosis, such as macular degeneration, retinitis pigmentosa, glaucoma, and cerebrovascular accidents or as a condition secondary to another primary diagnosis, such as diabetes mellitus or acquired immunodeficiency syndrome (AIDS). Low vision is not a normal sign of aging and will not improve with eyeglasses, medicine, or surgery.

Vision rehabilitation is considered medically necessary and, therefore, covered for any condition, disease, or injury that causes a visual impairment that results in functional limitation or disability. The rehabilitation process, which includes an evaluation, diagnosis, treatment, and education, helps individuals who are visually disabled attain maximum function, a sense of well-being, a personally satisfying level of independence, and optimum quality of life.

The purpose of rehabilitative therapy is to maximize the use of residual vision and provide individuals with many practical adaptations for activities of daily living. Rehabilitation appears to be more effective if it is started as soon as functional visual difficulties are identified.

SCHROTH THERAPY

NOT MEDICALLY NECESSARY

Schroth therapy for the treatment of scoliosis is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use.

VESTIBULAR REHABILITATION

MEDICALLY NECESSARY

Vestibular rehabilitation (e.g., canalith repositioning procedure) is a group of rehabilitative services used in the management of vestibular disorders. Vestibular rehabilitation is considered medically necessary and, therefore, covered for individuals with documented vestibular hypofunction or benign paroxysmal positioning vertigo (BPPV).

A diagnosis of a vestibular disorder is made by definitive testing consisting of one of the following:
  • Caloric testing for vestibular hypofunction
  • Rotary chair test for vestibular hypofunction
  • Dix-Hallpike maneuver test for BPPV
  • Head thrust test for vestibular hypofunction
Ménière's disease and perilymphatic fistula do not routinely require vestibular rehabilitation unless combined with therapy for functional deficits. Gait abnormality due to Mé​nière's disease and perilymphatic fistula does not justify the need for vestibular rehabilitation.

MAINTENANCE THERAPY

NOT MEDICALLY NECESSARY

The continued treatment of an individual when the maximum therapeutic goals of a treatment plan have been achieved and no additional functional improvement is apparent or expected to occur, sometimes referred to as maintenance therapy, is considered not medically necessary, and, therefore, not covered because the provision of services cease to be of therapeutic value.

COVERAGE LIMITATIONS

Services that are solely palliative in nature are considered not medically necessary and, therefore, not covered. These services would be focused on maintaining function and generally would not involve complex physical medicine and rehabilitative procedures, nor would they require clinician judgment and skill for safety and effectiveness.

If evaluation of the individual demonstrates that the individual does not have the potential to achieve significant improvement in, restoration of, and/or compensation for, loss of function in a reasonable and generally predictable period of time, or would not benefit from the establishment of a maintenance program, services would not be covered because they would not be considered medically necessary.

Therapy is not required to effect improvement or restoration of function where an individual suffers a transient and easily reversible loss or reduction of function (e.g., temporary weakness that may follow a brief period of bed rest following abdominal surgery), which could reasonably be expected to improve spontaneously as the individual gradually resumes normal activities. Therapy furnished in such situations is not considered medically necessary for the treatment of the individual's illness or injury, and the services are not covered.

Services related to specific employment opportunities (i.e., on the job training, work skills, or work settings) and activities for the general good and welfare of individuals (i.e., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation) do not constitute physical medicine and rehabilitative services.

Reimbursement for an evaluation will be limited to once per course of treatment. Many individuals may complete their course of physical medicine and rehabilitative services without ever needing a re-evaluation service, whereas others may need one or more re-evaluations performed during their course of treatment because of a change in status or needs.

Because manual therapy includes services other than manipulation, there may be a clinical indication for the individual to receive osteopathic manipulation and manual therapy on the same date of service. In this situation, the plan of care and other documentation must clearly support all services.

DOCUMENTATION

Documentation should be available for review upon request from the Company. The medical record should include the plan of care that has been written and developed by the eligible professional provider. The plan of care must be established prior to the initiation of therapy and signed by the provider.
The plan of care should include the following information:
  • The individual's significant history
  • The individual's diagnoses that require therapy
  • Any related physician or other qualified professional provider's orders
  • The goals for therapy, which should be specific and measurable, and the expected potential for achievement, which should include the type, amount, duration, and frequency of therapy services
  • Any contraindications to a course of therapy
  • The individual's awareness and understanding of the diagnoses, prognoses, and goals of therapy
  • When appropriate, a summary of past therapies and the results that were achieved
  • Supporting documentation of medical necessity when a modality/procedure is performed on the same day as a re-evaluation
Daily treatment and modality notes should include the following information:
  • Date of treatment
  • Specific treatment provided
  • If modalities are utilized, documentation of the length of time spent in each modality
  • If exercises or equipment are utilized, documentation of the specific activity, time, and/or number of repetitions
    • Exercises or modalities that require therapist supervision should be supported with an indication of the time spent and the level of skill required
  • Response to treatment
  • Skilled ongoing reassessment of the individual’s progress towards established goals
  • Objective, measurable, and specific documentation of progress towards goals using consistent and comparable methods
  • Changes to plan of care or objective reasoning for why the individual has not progressed towards goals
  • Name and credentials of the treating clinician
The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include, but are not limited to, the following: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.

THERAPY SESSIONS

If more than one Current Procedural Terminology (CPT) code is reported for a single date of service, then the total number of units that can be reported is based on the total treatment time. The average therapy session should last no more than 60 minutes. If additional therapy session time is required for more complex or slow-to-respond individuals, documentation of the exceptional circumstances must be included in the patient's medical record. ​

The total number of reported units is constrained by the total treatment time of all "timed" procedures provided on a given day. The "8 Minute Rule" is utilized to determine the total number of units to apply.

For any single CPT code, bill a single 15-minute unit as follows:

1 unit = greater than 8 minutes and less than 23 minutes
2 units = greater than 23 minutes and less than 38 minutes
3 units = greater than 38 minutes and less than 53 minutes
4 units = greater than 53 minutes and less than 68 minutes

The above unit/timing information is intended to provide assistance in rounding time into 15-minute increments. It does not imply that any time prior to the eighth minute should be excluded from the total count, as the timing of active treatment counted includes all time.

BILLING REQUIREMENTS

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.


To report habilitation services, append the following modifier: Modifier 96 - Habilitative services.

To report rehabilitation services, append the following modifier: Modifier 97 - Rehabilitative services.

To report occupational therapy services, append the following modifier: Modifier GO.

To report physical therapy services, append the following modifier: Modifier GP.

Modifier CO and CQ must be used to report services performed by an OT assistant or PT assistant.​

Guidelines

BENEFIT APPLICATION

MANDATES


This policy is consistent with applicable state mandates. The laws of the state where the group benefit contract is issued determines the mandated coverage.


Physical and occupational therapy services may be available for coverage in accordance with State Mandates for Autism Spectrum Disorders (ASD).​


Subject to the terms and conditions of the applicable benefit contract, outpatient physical therapy and occupational therapy (PT/OT) are covered under the medical benefits of the Company’s products. Individual member benefits must be verified, as benefits for outpatient PT/OT may vary by state, product, and group.​

Description

Rehabilitation therapy refers to healthcare services designed to improve, maintain, and prevent the deterioration of skills and functioning for daily living that have been lost or impaired. These services are provided by or under the supervision of an organized staff of professional providers.

Habilitation therapy refers to healthcare services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Physical therapy (PT) is a medically prescribed treatment for physical disabilities or impairments that result from disease, injury, congenital anomaly, and/or prior therapeutic intervention. PT employs the use of therapeutic exercise and other interventions that focus on locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, and the functional activities of daily living. The most commonly used interventions are exercise, heat, cold, electric energy, electric stimulation, ultraviolet light, ultrasound, hydrotherapy, manual therapy, and massage.

Occupational therapy (OT) is a medically prescribed intervention that involves the therapeutic use of self-care and other purposeful activities designed to help individuals with physical or developmental impairments increase independence with activities of daily living, enhance development, and/or prevent disability. Occupational therapy does not include services specifically directed toward the improvement of vocational skills and social functioning.

Maintenance therapy provides a continuation of care and management of an individual when the therapeutic goals of a plan of care have been achieved, no additional functional improvement is apparent or expected to occur, and the provision of services for a condition ceases to be of therapeutic value.

Orthotic management and prosthetic management is used to enhance the performance of tasks or movements, support weak or ineffective joints or muscles, reduce/correct joint limitations/deformities, and/or protect body parts from injury.

Prosthetic evaluation to ensure correct fit during functional activities (e.g., checking for skin integrity where the prosthetic device may apply pressure) is one test and measurement for orthotic and prosthetic management.

Therapeutic procedures are time-based physical medicine procedures that require direct one-on-one contact. These procedures are part of a short-term, goal-directed plan of care for an acute problem or condition that requires skilled intervention. These include treatments that attempt to reduce impairments and improve, restore, and/or compensate for loss of function through the application of clinical skills and services.

 LOW VISION

According to the American Optometric Association (AOA), low vision is defined as noncorrectable reduced vision. The AOA stratifies low vision by level of visual impairment as outlined below:
  • Near-normal vision (20/30 to 20/60)
  • Moderate low vision (20/70 to 20/160)
  • Severe low vision (20/200 to 20/400)
  • Profound low vision (20/500 to 20/1,000)
  • Near-total blindness (less than 20/1,000)
  • Total blindness (no light perception)
Diagnostic examinations for low vision include visual acuity testing, ocular motility assessments, and visual field integrity assessments. Services provided for individuals with low vision may include training to improve skills and functioning for activities of daily living. These services are provided by or under the supervision of an organized staff of eligible professional providers.

SCHROTH THERAPY

Schroth therapy, or physiotherapy scoliosis-specific exercises (PSSE) (as this intervention is sometimes referred to in the literature) is a treatment modality for adolescent idiopathic scoliosis (AIS) developed by Katharina Schroth in the early 20th century. Although the modality has been modified over the years, the key principles have remained constant and involve autocorrection, elongation, and chest wall expansion with integration of the “corrected” posture into daily life activities.

A 2012 Cochrane collaboration meta-analysis comprises the most comprehensive review of this intervention to date. In that study, Romano et al. reported the findings of a review of the literature investigating the efficacy and utility of PSSEs in the treatment of adolescents with AIS. Upon searching numerous databases for randomized controlled trials (RCTs) and prospective cohort studies, the authors' final review ultimately included two studies reporting on outcomes in 154 individuals. The primary outcomes of interest were progression of scoliosis (measured by Cobb angle in degrees), cosmetic issues, quality of life and disability, back pain, and psychological issues. Secondary outcomes were adverse events as identified in clinical trials. The authors found that there is a scarcity of high-quality evidence (only one RCT and one prospective cohort study). The included RCT found low-quality evidence that PSSE exercises as an adjunctive to other conservative treatments increase the efficacy of these treatments (thoracic curve reduced: mean difference [MD] 9.00; confidence interval [CI] 5.47–12.53; lumbar curve reduced: MD 8.00; CI 5.08–10.92). The prospective cohort study similarly found that PSSEs structured within an exercise program can reduce brace prescription: RR 0.24 (CI 0.06–​1.04) as compared with typical physiotherapy. The authors concluded that there is a lack of high-quality evidence to recommend the use of PSSE for AIS and that better-quality research needs to be conducted before the use of PSSE can be recommended in clinical practice.

Notable professional societies in the field of scoliosis treatment similarly note the dearth of high-quality evidence for Schroth therapy in the literature presently. The Scoliosis Research Society (SRS) in a 2014 statement, for example, states that there is presently insufficient evidence to advocate the use of PSSE programs in lieu of bracing (the conventional physiotherapeutic method in this cohort) in treating progressive idiopathic scoliosis. The Society, nonetheless, remains interested in further research into the role of PSSEs in plans of care.

In 2016, Berdishevsky et al. concluded that the evidence supporting the effectiveness of PSSE is growing, with more high-quality research studies being published in recent years. The research must continue in order to further study the effectiveness of the various schools and to determine which methods and which exercises are most beneficial for individuals.

LOW-LEVEL LASER THERAPY

Low-level laser therapy (LLLT), also referred to as photobiomodulation therapy (PBMT), is a light therapy in which lasers or light-emitting diodes (LEDs) are used to improve tissue repair and reduce pain and inflammation wherever the beam is applied. LLLT is also known as “cold laser" therapy because the power densities used in this treatment modality are lower than those needed to produce heating of tissue (as is the case in thermal ablation treatments, for example).

According to Chung et al. (2012), although LLLT is used to treat a wide variety of ailments (e.g., there are studies reporting on this intervention's use in individuals with neck pain, chronic wounds, arthritis, tuberculosis, smoking cessation, epicondylitis), this treatment remains controversial for two main reasons: its underlying mechanisms have not been fully elucidated, and effective treatment parameters such as wavelength, fluence, power density, and so on, are not efficiently described and delineated in the literature. As such, this treatment is largely investigational.​
INFRARED THERAPY

Infrared therapy is a treatment modality in which monochromatic infrared energy, using an array of juxtaposed infrared diodes, is affixed to a flexible pad to retain skin contact. Infrared therapy is used in the treatment of various conditions, including cutaneous ulcers, diabetic neuropathy, musculoskeletal and soft tissue injuries, including temporomandibular disorders, tendonitis, capsulitis, and myofascial pain.

A 2008 systematic review by Li et al. reported the findings of a collective analysis of clinical studies, including prospective and retrospective studies, evaluating infrared therapy in the treatment of diabetic neuropathy. Their search of the literature yielded 10 studies including four retrospective chart reviews, five studies with an experimental research design, and two RCTs. Although overall the review found that infrared therapy improved some outcomes, including lower-extremity sensation, balance, gait, and decreased fall risk, the authors concluded that the external validity of these studies was severely limited by poor study design methodologies of the assessed studies; e.g., about 60% of the included studies had fewer than 50 individuals; concomitant use of other physical therapy modalities could have confounded the results as well. Additionally, there was incomplete information regarding treatment volume or intensity. These limitations point to the need for better-designed studies to evaluate this treatment in this cohort.

A 2011 systematic review assessing the use of physical therapy for balance dysfunction in individuals with diabetic neuropathy similarly evaluated the role of infrared therapy in this cohort. The authors concluded that there is insufficient evidence to recommend infrared therapy as a treatment for balance dysfunction.

TESTS AND MEASUREMENTS

Physical performance tests or measurements may be used to provide objective documentation of an individual's condition or status that requires them to receive PT or OT services. Results of these tests may provide additional information that enables the therapist to develop or change the plan of care. These tests and measurements are over and above the typical evaluations that are performed.

Isokinetic muscle tests (i.e., quantitative muscle tests, isokinetic dynamometry) have been used in clinical research to quantify muscle strength and an individual’s response to rehabilitation and therapy. Several isokinetic devices (e.g., MedX lumbar and cervical extension devices, Isostation B-200 lumbar dynamometer, Kin-Com physical therapy isokinetic equipment, Cybex Back System, Biodex System 3, JTECH Tracker Freedom wireless muscle testing) have received US Food and Drug Administration approval. However, isokinetic muscle testing using an isokinetic dynamometry has not been medically proven to be more effective than established methods of muscle strength.

Assistive technology assessments are conducted to provide information about the interface between the individual's needs and the technology that is best suited to maximize function. The individual's voluntary motions (e.g., motor strength, range of motion and strength, motor control, and the individual's ability to use the accessibility components and systems) are identified and assessed. Multiple systems/components are tested to determine the optimal interface between the individual and various technology applications. Appropriateness and/or modification of commercial components are also evaluated.

References

Agency for Healthcare Research and Quality. Vision rehabilitation for elderly individuals with low vision or blindness. Available at: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/id95TA.pdf. Accessed December 07, 2023.


American Academy of Ophthalmology (AAO). Low vision diagnosis and treatment. [AAO Web site]. 2021. Available at: https://www.aao.org/eye-health/diseases/low-vision-diagnosis-treatment. Accessed December 07, 2023.

American Optometric Association (AOA). Low vision. [AOA Web site]. 2020. Available at: http://www.aoa.org/patients-and-public/caring-for-your-vision/low-vision?sso=y. Accessed December 07, 2023.

American Occupational Therapy Association (AOTA). The role of occupational therapy in providing seating and wheeled mobility services. [AOTA Web site]. 2021. Available at: https://www.aota.org/About-Occupational-Therapy/Professionals/RDP/Providing-Seating-Wheeled-Mobility-Services.aspx. Accessed December 07, 2023.

American Optometric Association (AOA). Vision rehabilitation. [AOA Web site]. 2020. Available at:  https://www.aoa.org/optometrists/tools-and-resources/vision-rehabilitation. Accessed December 07, 2023.

American Optometric Association (AOA). Optometric clinical practice guideline. [AOA Web site]. 2021. Available at:  https://www.aoa.org/practice/clinical-guidelines?sso=y. Accessed December 07, 2023.

American Psychiatric Association (APA). Conduct disorder. [APA Web site]. 2013. Available at: https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/APA_DSM-5-Conduct-Disorder.pdf​. Accessed January 03, 2024.

AquaMED Technology Assessment, Washington State Department of Labor and Industries.  Available at: https://www.lni.wa.gov/patient-care/treating-patients/treatment-guidelines-and-resources/_docs/AquaMedTA.pdf. Accessed December 07, 2023.

Berdishevsky H, Lebel VA, Bettany-Saltikov J, et al. Physiotherapy scoliosis-specific exercises: a comprehensive review of seven major schools. Scoliosis Spine Disord. 2016;11(1):20.

Centers for Medicare & Medicaid Services (CMS). Medicare Memo United Government Services, LLC. Documentation of therapy minutes for Medicare: UGS' guide to documentation expectations for supporting HCPCS codes and units billed. [Wisconsin Speech-Language Pathology and Audiology Professional Association Web site]. 01/21/05. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2121CP.pdf. Accessed February 27, 2023.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual; Chapter 5--Part B Outpatient Rehabilitation and CORF/OPT Services. Revised 11/22/2021.
Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c05.pdf. Accessed December 07, 2023.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health services. § 220 Coverage of outpatient rehabilitation therapy services. [CMS Web site]. 04/04/2022. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. Accessed December 07, 2023.


Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).150.1: Manipulation. [CMS Web site]. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=3&ncdver=1&bc=AAAAIAAAAAAA&. Accessed December 07, 2023.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).270.6: Infrared therapy devices. [CMS Web site]. Original: 10/24/2006. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=315&ncdver=1&bc=AgAAgAAAAAAA&. Accessed December 07, 2023.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 270.1: Electrical stimulation (ES) and electromagnetic therapy for the treatment of wounds. [CMS Web site]. Original: 07/01/2004. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=131&ncdver=3&NCSelection=NCD&DocID=270.1&kq=true&bc=IAAAABAAAAAA&. Accessed December 07, 2023.

Centers for Medicare & Medicaid Services (CMS). Medicare National Coverage Determinations Manual: Chapter 1, Part 2 (Sections 90-160.26) Coverage Determinations. §160.15: Electrotherapy for treatment of facial nerve palsy (Bell's palsy). [CMS website]. Revised 07/20/2021. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part2.pdf. Accessed December 07, 2023.

Centers for Medicare & Medicaid Services (CMS). Medicare National Coverage Determinations Manual: Chapter 1, Part 2 (Sections 90-160.26) Coverage Determinations. §160.2: Treatment of motor function disorders with electric nerve stimulation. [CMS website]. Revised 07/20/2021. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part2.pdf. Accessed December 07, 2023.


Centers for Medicare & Medicaid Services (CMS). Medicare National Coverage Determinations Manual: Chapter 1, Part 4 (Sections 200-310.1) Coverage Determinations. §270.6: Infrared therapy devices. [CMS website]. Revised 01/20/2022. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4pdf.pdf. Accessed December 07, 2023.

Chung H, Dai T, Sharma S, et al. The nuts and bolts of low-level laser (light) therapy. Ann Biomed Eng. 2012;40(2):516-533.

Company Benefit Contracts.

Hresko M. SRS Statement on Physiotherapy Scoliosis Specific exercises. 05/19/2014. Available at: https://www.srs.org/about-srs/quality-and-safety/position-statements/srs-statement-on-physiotherapy-scoliosis-specific-exercises. Accessed December 07, 2023.


Hydromassage LLC. Available at: http://www.hydromassage.com/. Accessed December 07, 2023.

Insurance Department of Banking and Insurance. Division of Insurance. Actuarial Services. Mandated Benefits for Biologically-Based Mental Illness. Adopted New Rules: N.J.A.C. 11:4-57. Adopted: June 3, 2015.

Li JC, Meyers AD, Roland PS, et al. Benign paroxysmal positional vertigo treatment & vertigo. [Medscape website]. 01/14/2022. Available at: http://emedicine.medscape.com/article/884261-treatment. Accessed December 07, 2023.


Novitas Solutions Inc. Local Coverage Determination (L35036). Therapy and Rehabilitation Services [Novitas Solutions Web site]. Original:10/01/2015. (Retired: 03/01/2023).  Available at:
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=35036&ver=119. Accessed December 07, 2023.

Novitas Solutions. Local coverage Determination (LCD). L-33942: Physical Therapy-Home Health [Novitas Solutions Web site]. Original: 10/01/2015. (Revised: 07/06/2023). Available at:
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=33942&ver=46. Accessed December 07, 2023.

Novitas Solutions, Inc. Local Coverage Article A57311. Billing and coding: physical therapy-home health. [Novitas Solutions, Inc. Web site] 09/26/2019. (Revised: 10/01/2023).  Available at:  https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57311&ver=25. Accessed December 08, 2023.

Novitas Solutions, Inc. Local Coverage Article A57703. Billing and coding: therapy and rehabilitation services (PT, OT). [Novitas Solutions, Inc. Web site] 11/14/2019. (Retired: 03/01/2023). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57703&ver=11&bc=0. Accessed December 08, 2023.

Romano M., Minozzi S, Bettany-Saltikov J. et al. Exercises for adolescent idiopathic scoliosis (review). Cochrane Database Syst Rev. 2012 Aug 15;8:CD007837. doi: 10.1002/14651858.CD007837.pub2.  

Sidmar Manufacturing, Inc. Hydromassage tables. Available at: https://sidmar.com/. Accessed December 08, 2023.

US Food and Drug Administration (FDA). Center for Medical Devices. Devices @ FDA. Device Detail: Biodex [FDA Website]. 03/10/1995.  (Updated 02/27/2023). Available at:  https://www.accessdata.fda.gov/SCRIPTS/cdrh/devicesatfda/index.cfm?db=pmn&id=K942694. Accessed December 08, 2023.


Weber D, Brown A. Physical agent modalities. In: Braddom RL, Buschbacher RM, eds. Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, PA: W.B. Saunders Company; 2000: 440-55.​​

Coding

CPT Procedure Code Number(s)
MEDICALLY NECESSARY

95992, 97012, 97014, 97016, 97018, 97022, 97024, 97028, 97032, 97033, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97763

THE FOLLOWING UNLISTED CODES SHOULD BE USED ONLY WHEN THERE IS NO APPROPRIATE CODE AVAILABLE:

97039, 97139, 97799

BENEFIT EXCLUSION

97169, 97170, 97171, 97172, 97545, 97546

EXPERIMENTAL/INVESTIGATIONAL

97026, 97037

THE FOLLOWING CODE IS USED TO REPRESENT DRY HYDROTHERAPY (e.g. AquaMED, Sidmar) ​

97039​

THE FOLLOWING SERVICE IS NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT:

97010
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
THE FOLLOWING CODES REPRESENT LOW VISION DIAGNOSES:

H53.411 Scotoma involving central area, right eye

H53.412 Scotoma involving central area, left eye

H53.413 Scotoma involving central area, bilateral

H53.419 Scotoma involving central area, unspecified eye

H53.421 Scotoma of blind spot area, right eye

H53.422 Scotoma of blind spot area, left eye

H53.423 Scotoma of blind spot area, bilateral

H53.429 Scotoma of blind spot area, unspecified eye

H54.0X33 Blindness right eye category 3, blindness left eye category 3

H54.0X34 Blindness right eye category 3, blindness left eye category 4

H54.0X35 Blindness right eye category 3, blindness left eye category 5

H54.0X43 Blindness right eye category 4, blindness left eye category 3

H54.0X44 Blindness right eye category 4, blindness left eye category 4

H54.0X45 Blindness right eye category 4, blindness left eye category 5

H54.0X53 Blindness right eye category 5, blindness left eye category 3

H54.0X54 Blindness right eye category 5, blindness left eye category 4

H54.0X55 Blindness right eye category 5, blindness left eye category 5

H54.10 Blindness, one eye, low vision other eye, unspecified eyes

H54.1131 Blindness right eye category 3, low vision left eye category 1

H54.1132 Blindness right eye category 3, low vision left eye category 2

H54.1141 Blindness right eye category 4, low vision left eye category 1

H54.1142 Blindness right eye category 4, low vision left eye category 2

H54.1151 Blindness right eye category 5, low vision left eye category 1

H54.1152 Blindness right eye category 5, low vision left eye category

H54.1213 Low vision right eye category 1, blindness left eye category 3

H54.1214 Low vision right eye category 1, blindness left eye category 4

H54.1215 Low vision right eye category 1, blindness left eye category 5

H54.1223 Low vision right eye category 2, blindness left eye category 3

H54.1224 Low vision right eye category 2, blindness left eye category 4

H54.1225 Low vision right eye category 2, blindness left eye category 5

H54.2X11 Low vision right eye category 1, low vision left eye category 1

H54.2X12 Low vision right eye category 1, low vision left eye category 2

H54.2X21 Low vision right eye category 2, low vision left eye category 1

H54.2X22 Low vision right eye category 2, low vision left eye category 2

H54.3 Unqualified visual loss, both eyes

H54.40 Blindness, one eye, unspecified eye

H54.413A Blindness right eye category 3, normal vision left eye

H54.414A Blindness right eye category 4, normal vision left eye

H54.415A Blindness right eye category 5, normal vision left eye

H54.42A3 Blindness left eye category 3, normal vision right eye

H54.42A4 Blindness left eye category 4, normal vision right eye

H54.42A5 Blindness left eye category 5, normal vision right eye

H54.50 Low vision, one eye, unspecified eye

H54.511A Low vision right eye category 1, normal vision left eye

H54.512A Low vision right eye category 2, normal vision left eye

H54.52A1 Low vision left eye category 1, normal vision right eye

H54.52A2 Low vision left eye category 2, normal vision right eye

H54.60 Unqualified visual loss, one eye, unspecified eye

H54.61 Unqualified visual loss, right eye, normal vision left eye

H54.62 Unqualified visual loss, left eye, normal vision right eye

H54.7 Unspecified visual loss

H54.8 Legal blindness, as defined in USA



FOR 95992 , THE FOLLOWING DIAGNOSIS CODES ARE CONSIDERED MEDICALLY NECESSARY:

H81.10 Benign paroxysmal vertigo, unspecified ear

H81.11 Benign paroxysmal vertigo, right ear

H81.12 Benign paroxysmal vertigo, left ear

H81.13 Benign paroxysmal vertigo, bilateral



FOR 97033, THE FOLLOWING DIAGNOSIS CODES ARE CONSIDERED MEDICALLY NECESSARY

L74.510 Primary focal hyperhidrosis, axilla

L74.511 Primary focal hyperhidrosis, face

L74.512 Primary focal hyperhidrosis, palms

L74.513 Primary focal hyperhidrosis, soles

L74.519 Primary focal hyperhidrosis, unspecified
HCPCS Level II Code Number(s)
MEDICALLY NECESSARY

G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care

S8950 Complex lymphedema therapy, each 15 minutes

S9476 Vestibular rehabilitation program, nonphysician provider, per diem


NOT MEDICALLY NECESSARY

​S8990 Physical or manipulative therapy performed for maintenance rather than restoration

THE FOLLOWING CODE IS USED TO REPRESENT SCHROTH THERAPY
S9117 Back school, per visit


EXPERIMENTAL/INVESTIGATIONAL

S8948 Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes
Revenue Code Number(s)
0420 Physical Therapy-General

0421 Physical Therapy-Visit Charge

0422 Physical Therapy-Hourly Charge

0423 Physical Therapy-Group Rate

0424 Physical Therapy-Evaluation or Reevaluation

0429 Physical Therapy-Other Physical Therapy

0430 Occupational Therapy-General

0431 Occupational Therapy-Visit Charge

0432 Occupational Therapy-Hourly Charge

0433 Occupational Therapy-Group Rate

0434 Occupational Therapy-Evaluation or Reevaluation

0439 Occupational Therapy-Other Occupational Therapy

Modifiers

CO Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant

CQ Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant

GO Services delivered under an outpatient occupational therapy plan of care

GP Services delivered under an outpatient physical therapy plan of care

96 Habilitative Services

97 Rehabilitative Services

Coding and Billing Requirements

Policy History

Revisions From 10.03.01o:
01/15/2024                       ​     
​This version of the policy will become effective 01/15/2024​.

The following criteria have been added to this policy: Low-level laser therapy (LLLT), also referred to as Photobiomodulation Therapy, is considered experimental/investigational and, therefore, not covered, because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature. ​​

The following billing requirements have been added to this policy:

  • To report occupational therapy services, append the following modifier: Modifier GO.
  • To report physical therapy services, append the following modifier: Modifier GP.​​
The following new CPT code was added to the experiemental/investigational section of this policy: 97037.​

This policy has been updated in consideration of State Mandates for Autism Spectrum Disorders (ASD).

Revisions From 10.03.01n:
​06/28/2023
​This policy has been reviewed and reissued to communicate the Company's continuing position on Outpatient Physical Medicine and Rehabilitation Services. ​
08/29/2022

This version of the policy will become effective 08/29/2022.

The following billing requirements have been added to this policy:
  • To report rehabilitation services, append the following modifier: Modifier 97-Rehabilitative services.
  • Modifier CO and CQ must be used to report services performed by an occupational therapy assistant or physical therapy assistant.​

Revisions From 10.03.01m:
12/20/2021

This version of the policy will become effective 12/20/2021.

The policy has been updated to communicate the Company's experimental/investigational position for dry hydrotherapy.​

​The title of this policy has been changed from "Physical Medicine, Rehabilitation, and Habilitation Services​" to "Outpatient Physical Medicine, Rehabilitation, and Habilitation Services".​

Revisions From 10.03.01l:
06/30/2021

The policy has been reviewed and reissued to communicate the Company's continuing position on Physical Medicine, Rehabilitation, and Habilitation Services​.
​04/01/2020
This version of the policy will become effective 04/01/2020.
This policy has been updated in consideration of revised Maintenance therapy language.
The following HCPCS codes have been removed from this policy: G0281, G0282,
G0329, and G0295.

Revisions From 10.03.01k:
01/01/2020This version of the policy will become effective 01/01/2020.

The following CPT code has been termed from th​is policy: 97127.
The following HCPCS code has been termed from this policy: G0515.
The following CPT codes have been added to this policy: 97129 and 97130.

Revisions From ​10.03.01j:
12/18/2019This policy has been reissued in accordance with the Company's annual review process.
​01/28/2019

​This version of the policy will become effective 01/28/2019

This policy has been updated in consideration of existing benefit coverage revision for Massage Therapy.

This policy has been updated to remove Maintenance Therapy as a Benefit Contract Exclusion.

The following criteria have been added to this policy: Isokinetic muscle tests/quantitative muscle tests with an isokinetic dynamometer (e.g., Biodex, Cybex) is considered not medically necessary and therefore not covered.

The following ICD-10 CM codes have been added to this policy: L74.510, L74.511, L74.512, L74.513, L74.519.

Revisions From 10.03.01i:
01/01/2018This policy has been identified for the CPT / HCPCS / Modifier code update, effective 01/01/2018.

The following CPT / HCPCS / Modifier codes have been termed from this policy:
97532, 97762, SZ

The following CPT / HCPCS codes have been added to this policy:
97127, 97763, G0515, 96, 97

The following CPT narratives have been revised in this policy:
97760, 97761

Effective 10/05/2017 this policy has been updated to the new policy template format.
1/15/2024
1/15/2024
10.03.01
Medical Policy Bulletin
Commercial
No
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.