This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Coverage for physical medicine is determined according to individual or group customer benefits.

Physical medicine is a covered service when performed with the expectation of restoring the patient's level of function that has been lost or reduced by injury or illness.

Treatment plans must be maintained in the medical record, and made available upon request.

A typical session usually consists of up to one (1) hour of rehabilitative therapy which could include up to four (4) physical medicine modalities/procedures and/or units performed on the same date of service, per performing provider.

Reimbursement for PT/OT visits involving any of the physical medicine codes are limited as follows:

• Up to four (4) codes/units in any combination per date of service per performing provider.
• Payment will be based on the highest submitted and allowed physical medicine codes.
  • Modalities- 97012-97039, G0283, S8950
  • Therapeutic procedures- 97110-97542
  • Tests and measurements 97750
  • Muscle range of motion testing- 95831-95852
  • Orthotic management and prosthetic management- 97760-97762

Services exceeding the limitation will be considered not medically necessary.

Duplicate therapy is not considered medically necessary.

Physical Medicine Evaluation
An Evaluation and Management (E&M) service is considered an inherent part of a physical medicine evaluation. The E&M service is not eligible for separate payment when reported on the same day as a physical medicine evaluation.

When an Evaluation and Management service is reported in conjunction with a physical medicine evaluation the services should be combined under the appropriate code for the physical medicine evaluation.

Modifier "-25" may be reported with medical care (e.g. E/M visits, consultations) to identify it as significant and separately identifiable from the other service(s) provided on the same day. When modifier "-25" is reported, the patient’s medical records must clearly document that separately identifiable medical care was rendered.

Muscle testing, range of motion testing, and physical performance testing are considered components of a physical medicine evaluation and are not eligible for separate payment when billed on the same date of service as a physical medicine evaluation.

Modifier "-59" may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day.

Maintenance Therapy
Physical medicine services performed repetitively to maintain a level of function is not eligible for payment unless the member has Habilitative Services benefits. A maintenance program consists of activities that preserve the patient's present level of function and prevent regression of that function. These services generally would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Maintenance therapy should be reported under procedure code S8990 (physical or manipulative therapy performed for maintenance rather than restoration), and not eligible for payment.

Habilitative Therapy
Physical medicine services ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury. This also includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.

Habilitative therapy services should be reported with the SZ modifier in conjunction with the appropriate therapy code. Habilitative therapy is not eligible for payment, unless the member has a habilitative benefit.

*Spinal manipulation is not considered an habilitative service.

Supervised Modalities
Supervised modalities do not require direct one-on-one patient contact by the provider. These are not time-based codes.

Vasopneumatic Compression (97016)
This treatment is warranted for the following conditions:

• Edema of the extremities
• Hematoma of the leg
• Lymphedema of the arm
• Lymphedema of the leg
• Venous insufficiency or venous stasis disorder

Conditions other than those listed above or those which indicate that an infection is present should be denied as not medically necessary.

This service is considered a “supervised” modality and is not considered “time-based.” It should be reported only once per treatment session, regardless of the number of areas treated or the length of time required to complete treatment.

Services provided by devices that provide both vasopneumatic compression and cold therapy simultaneously, should be reported with code 97016.

Infrared Therapy (97026)
The use of infrared and near-infrared light and heat, including monochromatic infrared energy, is not considered medically necessary when used as a physical medicine modality for the treatment of diabetic and/or non-diabetic peripheral sensory neuropathy and wounds and/or ulcers of the skin and/or subcutaneous tissues.

Constant Attendance Modalities
Constant attendance modalities are those modalities that require direct one-on-one patient contact by the provider. Documentation must include the amount of time spent in providing all aspects of this service.

When two constant attendance modalities are performed at the same time, using one device, the code representing the primary modality should be reported.

Aquatic Therapy
Aquatic therapy must be performed with the expectation of restoring a patient's level of function that has been lost or reduced by injury or illness. Aquatic therapy performed to maintain a level of function is considered to be a maintenance program and is not eligible for payment.

A provider must have direct (one to one) patient contact when reporting aquatic therapy.

Before beginning an aquatic therapy program, the provider must prepare a treatment plan that includes short-term and long-term goals that the patient can be reasonably expected to accomplish through the aquatic therapy program and the specific methods chosen.

Separate payment will not be made for whirlpool or Hubbard tank in addition to aquatic therapy with therapeutic exercise for a single patient encounter.

Gait Training
Generally accepted indications for gait training include:

• Foot drop resulting from stroke
• Herniated disc(s)
• Ankle, knee and/or hip replacement
• Traumatic amputations of the toe(s)

Documentation for gait training must demonstrate that the patient's gait was improved either by lengthening the gait or increasing the frequency of cadence lower-extremity.

• Procedure code 97116 should not be used to report orthotics or prosthetics training.
• Orthotics training should be reported using procedure codes 97760 and 97762.
• Prosthetics training should be reported using procedure codes 97761 and 97762.

Vestibular Rehabilitation Therapy
A vestibular rehabilitation program typically last 45 minutes per session and is prescribed 1-2 times per week. In general, patients remain in the program 4-8 weeks.

A vestibular rehabilitation program may be considered medically necessary for patients with vertigo, disequilibrium, and balance deficits related to the following conditions:

• peripheral vestibular disorders (e.g., labyrinthitis, neuritis, benign paroxysmal positional vertigo, post vestibular surgical symptoms, and bilateral vestibular loss),
• mixed {peripheral and central vestibular disorders, and
• central causes of vertigo (e.g., CVA, multiple sclerosis, and mild traumatic brain injury)

If none of these conditions are reported, a vestibular rehabilitation program is considered not medically necessary.

Act 62 – 2008 (Autism Spectrum Disorders Coverage Mandate) Effective July 1, 2009
Act 62-2008 (Autism Spectrum Disorders Coverage Mandate) requires coverage for individuals who are under twenty-one (21) years of age for the diagnostic assessment and treatment of autism spectrum disorders.

Coverage is subject to a maximum benefit of forty thousand dollars ($40,000) per year, for policies issued or renewed in calendar year 2013. For policies that have renewal periods and benefit periods that differ, the new maximum benefit does not become effective until the subsequent benefit period. Coverage is not subject to any limits on the number of visits to an autism service provider for treatment of autism spectrum disorders. Coverage is subject to copayment, deductible and coinsurance provisions, as well as any other general exclusions or limitations set forth in the member’s contract.

Hot/Cold Packs
Hot/Cold Packs are not a covered service, therefore no payment will be made.  A network provider cannot bill the member for these services.

Not Medically Necessary

• Dry Hydro Massage

Experimental/Investigational

• Electromagnetic Stimulation
• Equestrian/Hippotherapy
• Low-Intensity Pulsed Ultrasound (Hands-Free Ultrasound)
• Horizontal Therapy
• Low-Level Laser Therapy (Cold Laser Therapy)
• Phonophoresis

For information on sensory integrative techniques, refer to Medical Policy Bulletin Y-2.

For information on manipulation services, refer to Medical Policy Bulletin Y-9.

For information on MLD, refer to Medical Policy Bulletin Y-11.

For information on cognitive rehabilitation, refer to Medical Policy Bulletin Y-21.

For information on interferential stimulation, refer to Medical Policy Bulletin E-45.

For information on electromagnetic therapy provided for the treatment of urinary incontinence, see Medical Policy Bulletin Y-12.

For information on Autism Spectrum Disorders, refer to Medical Policy Bulletin V-37.

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Physical Medicine is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances including, but not limited to the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services denied as not reasonable and medically necessary, under section 1862(a)(1) of the Social Security Act, are subject to the Limitation of Liability provision. A contracted provider must inform the enrollee to request an organization determination from the plan or the provider can request the organization determination on the enrollee’s behalf. Failure to provide a compliant denial to the enrollee means that the enrollee is not liable for services provided by a contracted provider or upon referral from a contracted provider.

• Link to Diagnosis Codes

• Link to References