MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Physical Medicine and Rehabilitation - Physical Therapy and Medical Massage Therapy

Number 8.03.502*

Effective Date February 15, 2014

Revision Date(s) 09/09/13, 08/12/13; 10/09/12; 11/09/11; 05/10/11; 02/08/11; 02/09/10; 02/10/09; 08/12/08; 07/10/07; 05/13/03; 12/10/02; 05/05/97

Replaces 8.03.02

*Medicare has a policy

Policy

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Physical Medicine and Rehabilitation – Physical Therapy (PM&R-PT), including medical massage therapy services, may be considered medically necessary when performed to meet the functional needs of a patient who suffers from physical impairment, functional limitation or disability due to disease, trauma, congenital anomalies, or prior therapeutic intervention.

Physical medicine and rehabilitation – physical therapy (PM&R – PT), including medical massage therapy services may be considered medically necessary when ALL of the following criteria are met:

  • The patient has a documented physical impairment, functional limitation or disability due to disease, trauma, congenital anomalies, or prior therapeutic intervention AND
  • The patient has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time based on specific diagnosis-related treatment/therapy goals AND
  • The service is delivered by a qualified provider of PM&R-PT or massage therapy services AND
  • Due to the physical condition of the patient, the complexity and sophistication of the therapy and the therapeutic modalities used; the judgment, knowledge, and skills of a qualified PM&R-PT or medical massage therapy provider are required.

Medical Massage Therapy

Medical Massage therapy may be considered medically necessary as the only therapeutic intervention when ALL of the above criteria are met and:

  • The diagnosis-specific prescription, from the attending clinician with prescribing authority, stating the number of medical massage therapy visits is retained in the member’s massage therapy medical record and
  • The diagnosis-specific plan of care, approved by the attending clinician with prescribing authority, is retained in the member’s massage therapy medical record.

Physical Medicine and Rehabilitation – Physical Therapy (PM&R-PT), including medical massage therapy services may be considered not medically necessary when:

  • It is not part of a written plan of care for treatment of a specific diagnosis
  • The services do not ordinarily require the skills, sophistication, and full attention of a qualified provider
  • The patient is asymptomatic or without documented physical signs or functional symptoms of acute disability

Home-Based Therapy

Home-based Physical Therapy (PM&R-PT), including medical massage therapy services may be considered medically necessary when the patient is homebound and other medical necessity criteria detailed in this policy are met. (Refer to the Policy Guidelines for homebound information).

Maintenance Therapy Programs

Maintenance therapy programs are considered not medically necessary. (Refer to the Policy Guidelines).

Non-skilled Therapy

Certain types of treatment that do not generally require the skills of a qualified provider of PM&R-PT and/or medical massage therapy services are considered not medically necessary. (Refer to the Policy Guidelines).

Related Policies

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1.01.517

Home Traction Devices: Cervical and Lumbar

1.01.523

Heating Pads, Heat Lamps, Paraffin Bath, Hydrocollator Treatments in the Home

7.01.551

Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy

8.03.501

Chiropractic Services

8.03.503

Occupational Therapy

8.03.505

Speech Therapy

10.01.500

Skilled Nursing Care in the Home

Policy Guidelines

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Physical Therapy

Physical therapy (PT) is a form of rehabilitation with an established theoretical and scientific base and widespread clinical applications in the restoration, conservation, and promotion of optimal physical function.

Medical Massage Therapy

Medical massage, also called therapeutic massage, is outcome-based massage, using specific treatment modalities targeted to the functional problem(s) or diagnosis provided by the primary licensed clinician with prescribing authority.

Medical massage therapy or therapeutic massage may be provided by various qualified providers. (Refer to the Benefit Application section.)

Massage therapists, one type of medical massage provider, are required to be licensed by most states where the service is performed. The patient must be referred to the massage therapist by a licensed clinician with prescribing authority who writes a diagnosis-specific prescription for medical massage and approves the plan of care for a specific number of therapy visits.

Definitions

Activities of Daily Living

Activities of Daily Living (ADL) training: including but not limited to bathing, feeding, preparing meals, toileting, walking, making a bed, and transferring from bed to chair, wheelchair or walker, are covered when the skills of a professional provider are required, and the Plan of Care is designed to address the specific needs of the patient. Specific outcomes must be identified. Services provided concurrently by physical therapists and occupational therapists may be covered if there are separate and distinct functional goals.

Additional skilled services of a physical therapist may include assuring patient safety, training the patient, family, patients and/or caregivers, and infrequent but not routine reevaluations of the patient with possible revisions to the Plan of Care or home program.

Homebound

Homebound means the patient’s medical condition prevents him/her from leaving home independently and that leaving home requires a considerable and taxing effort. (The patient may leave home, but absences should be infrequent, of short duration, and mainly for receiving medical treatment). Homebound status may be applied to patients with a compromised immune system or debilitated health status when reverse isolation precautions are recommended by their health care provider to limit exposure to communicable illnesses. Examples of this are premature infants, patients undergoing chemotherapy, patients with a chronic disease that lowers immunity and resistance to disease. Homebound status also applies to those patients that require assistance when performing ADLs (e.g. transferring, walking or eating etc.).

Note: Homebound status is based on the patient’s medical condition and is not determined by the lack of/or availability of transportation, lack of access to a car or the inability to drive.

Maintenance Program

A maintenance program consists of activities that preserve the patient’s present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of the Plan of Care have been achieved, or when no additional functional progress is apparent or expected to occur. This may apply to patients with chronic and stable conditions where skilled supervision is no longer required and clinical improvement is not expected. The specialized knowledge and judgment of a qualified provider may be required to establish a maintenance program; however, the repetitive PM&R-PT and/or medical message therapy services needed to maintain a level of function would not be covered.

Examples of maintenance therapy may include, but are not limited to:

  • Additional PM&R-PT and/or medical massage therapy services when the patient’s chronic medical condition has reached maximum functional improvement
  • PM&R-PT and/or massage therapy services that enhance performance beyond what is needed to accomplish routine functional tasks
  • Preserving and maintaining range of motion by passive stretching exercises that are performed by non-skilled personnel
  • A home exercise program that is not focused on the identified impairments or functional limitations.

Non-Skilled Services

Types of treatment that do not generally require the skills of a qualified provider of PM&R-PT and/or medical massage therapy services may include but are not limited to:

  • Activities which the patient performs without direct supervision of a qualified provider such as treadmill, stationary bike, or other aerobic activity for warm-up or general conditioning
  • Modalities which the patient self-applies without direct supervision of a qualified provider, such as traction, automobilization tables (Spinalator, Anatamotor, etc.) or Wobble chairs
  • Passive range of motion (PROM) treatment, that is not related to restoration of a specific loss of function

Plan of Care

The goal driven plan of care details the therapeutic interventions to guide health care professionals involved with the patient’s care. Goals are linked to the outcomes to be measured in order to assess and monitor the effectiveness of the therapy program. (Refer to Benefit Application).

Coding

Physical Therapy

Fluidized Therapy (Fluidotherapy®) is a dry heat whirlpool using particles (sand-sized ground corn cobs) in a heated air stream. This physical therapy service may be billed with these CPT codes with documentation of the therapy provided:

97022 Application of a modality to 1 or more areas; whirlpool

97139 Unlisted therapeutic procedure (specify)

Note: Refer to Coding section for additional codes related to PM&R-PT modalities.

Medical Massage Therapy

CPT codes for massage therapy are:

97124 Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)

97140 Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

Description

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Physical medicine and rehabilitation – physical therapy (PM&R-PT) and medical massage therapy services focus on the treatment of impairments, functional limitations or disability caused by disease, congenital anomalies, injury, or prior therapeutic intervention. Treatment through physical means and interventions used, are based on biomechanical and neurophysiological principles, that focus on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, a person’s ability to go through the functional activities of daily living, and alleviating pain. The outcome-based plan of care and goals for the rehabilitation therapies are patient-centered and related to a specific diagnosis.

Scope

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Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

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In some plans, the benefits available for Physical Medicine Rehabilitation – Physical Therapy and Medical Massage Therapy include a fixed number of treatment visits covered per year regardless of the patient’s condition or prescribed number of courses of therapy. When the maximum benefit is reached coverage will stop.

Qualified Provider

Qualified providers of PM&R-PT services and medical massage therapy may include, but are not limited to:

  • Advanced Registered Nurse Practitioner (ARNP) (ANP)
  • Doctor of Chiropractic/Chiropractor (DC) (See Related Policies)
  • Doctor of Osteopathy/Osteopathic Physician (DO)
  • Doctor of Podiatric Medicine/Podiatrist (DPM) (limited by licensure requirements)
  • Licensed massage practitioner/therapist (LMP, LMT) (subject to the member’s health plan benefit)
  • Medical Doctors (MD)
  • Naturopathic Physician (ND)
  • Occupational Therapist (OT) (See Related Policies)
  • Physical Therapist (PT)

Note: Qualified providers of PM&R-PT services and medical massage therapy must meet the definition in the member’s health benefit plan contract. Please refer to the member’s benefit booklet or contact a customer service representative for specific language to determine coverage for the provider of service. (See Scope).

Therapy Visit

A PM&R-PT and/or medical massage therapy visit is defined as up to one hour per day. These visits may include, but are not limited to the following:

  • Chiropractic or osteopathic manipulative therapy
  • Massage modalities including, but not limited to effleurage, petrissage, tapping and friction
  • Patient and family education in home exercise programs
  • Therapeutic exercise programs, including coordination and resistive exercises, to increase strength and endurance
  • Traction, or mobilization techniques
  • Various modalities including, but not limited to, thermotherapy, cryotherapy, and hydrotherapy

Note: The initial evaluation, as well as periodic reevaluations and assessments, may be performed as a separate service on the same day as the therapy visit described above.

Documentation Requirements

The clinical impression, diagnosis and treatment care plan documented for the initial and the follow-up visits must clearly support the medical necessity of the rehabilitation therapy provided.

Documentation must be legible and include:

  • A key for any symbols, abbreviations or codes that are used by the provider and/or staff
  • Brief notations, check boxes, and codes/symbols for treatment are acceptable if the notations refer to a treatment modality that has been described in the current treatment plan
  • Initials of the provider of service and any staff/employees who provide services

Documentation of objective findings include the following information:

  • A statement of the patient’s complaint
  • Signs and symptoms of impairment or injury
  • Signs or symptoms of the patient’s inability to perform activities of daily living (ADLs)

The treatment plan of care:

  • Is patient-centered and appropriate for the symptoms, diagnosis and care of the condition
  • Includes objectively measurable short and long-term goals for specific clinical and/or functional improvements in the patient’s condition with an estimated completion date
  • Details the specific modalities and procedures to be used in treatment
  • Is approved by the referring physician (if applicable)

A reevaluation of the patient’s progress is completed at each follow-up visit and includes documentation of:

  • Objective physical findings of the patient’s current status
  • The patient’s subjective response to treatment
  • Measured clinical and/or functional improvement in the patient’s condition
  • A review of the treatment plan of care along with progress toward the short and long-term goals
  • Updates to the initial treatment plan of care with new goals that are appropriate to the patient’s condition
  • Reporting to the referring clinician with prescribing authority (if applicable) about the therapy outcomes and recommendations for follow up

Rationale

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This policy was originally created in 1997. Since that time the policy has been reviewed and updated using MEDLINE literature searches. The most recent update with literature review covered the period of August 2012 through June 2013. Following is a summary of the key literature.

Physical therapy consists of treatment modalities prescribed to restore lost functional ability. Some of the therapeutic interventions include heat and cold, electrical stimulation, massage, therapeutic exercises, traction, gait training for ambulation and training in other functional activities. (1) There are case studies found, however, few RCTs exist that address physical therapy modalities/manual medicine treatment as distinct from a comprehensive rehabilitation program.

In 2007 Taylor and colleagues (2) summarized the benefits of therapeutic exercise based on a systematic review of the literature published from 2002-2005. The review extracted 36 studies that were classified into groups based on condition. The conditions were 6-cardiopulmonary, 6-neurology, 20-musculoskeletal (including: spinal n=7; peripheral n=9, arthritis n=4), and 4-other. Therapeutic exercise was found to be effective for patients with multiple sclerosis, osteoarthritis, subacute and chronic low back pain, chronic heart failure, coronary heart disease, chronic heart failure, coronary heart disease, chronic obstructive pulmonary disease (COPD), and intermittent claudication and after lumbar disc surgery. Outcomes measured the effect of therapeutic exercise in terms of physical impairment, and restriction or limitation to active participation in ADLs. The conclusions state that focused, patient-centered therapeutic exercise programs were effective; however, some of the trials were of poor quality.

In 2011, Cherkin and colleagues published results from a parallel-group randomized control trial (RCT) (NCT000371384) on the effects of 2 types of massage and usual care on chronic low back pain. Patients (n=401) with low back pain of no identified cause lasting at 3 months were randomly assigned to get relaxation massage (n=136), structural massage (n=132) or usual medical care (analgesic, anti-inflammatory, muscle relaxing drugs) without massage (n=133). Patients assigned to the massage groups received 1 hour of massage once a week for 10 weeks. The researchers measured patients' symptoms and ability to perform daily activities using the Roland Disability Questionnaire (RDQ) and symptom bothersomeness scores before starting the interventions and again after completing the 10 massage treatments, and then at 6 months and 1 year after starting massage therapy. (3) The researchers found that patients who received massage had less pain and were able to perform daily activities better after 10 weeks than those who received usual care. The benefits of massage lasted for 6 months but were less clear at 1 year, when both pain and functional improvement were about equal in all 3 groups. The type of massage did not seem to make a difference. Symptoms and ability to perform activities improved about the same in the 2 massage groups. Study limitations were that the patients were not blinded to the treatment and the patients were mostly middle-aged, female and white which may limit applicability of the research findings to the general population.

In 2012, Perlman et. al. published the results of a RCT to determine the optimal “dose” of Swedish massage therapy for study participants identified with painful osteoarthritis (OA) of the knee. (NCT00970008) “The researchers defined optimal, practical dose as producing the greatest ratio of desired effect compared to costs in time, labor and convenience”. (4) Participants (n=125) with OA of the knee were randomly assigned to one of four 8-week doses of a standardized regimen of Swedish massage therapy (30 or 60 minutes weekly or biweekly) or to a Usual Care control group. The Usual Care control group continued with their current treatment plan and did not receive massage therapy. The primary outcome measure was a change in the Western Ontario and McMaster Universities Arthritis Index (WOMAC-Global). Three researchers assessed the 125 enrolled participants’ pain, function, and joint flexibility. One hundred nineteen participants completed the 8-week trial and 115 completed the entire 24 week trial. Conclusion by the authors: Based on the convenience of a once-weekly protocol, cost savings, and consistency with a typical real-world massage protocol, the 60-minute once weekly dose was determined to be optimal, potentially establishing a standard for future clinical trials.

Medicare National Coverage

“Part A covers medically necessary physical therapy services that are ordered by a physician under home health services if the patient is homebound. Part B helps pay for medically necessary outpatient physical therapy services that are ordered by a physician. Physical therapy services: include testing, measurement, assessment and treatment of the function, or dysfunction, of the neuromuscular, musculoskeletal, cardiovascular and respiratory system, and establishment of a maintenance therapy program for an individual whose restoration potential has been reached”. (5)

Practice Guidelines and Position Statements

The APTA (American Physical Therapy Association) publishes positions and policies, the most recent revisions are available at www.apta.org. (6) It includes Guidelines for Physical Therapy Documentation:

“It is the position of the APTA that physical therapist examination, evaluation, diagnosis, and prognosis shall be documented, dated, and authenticated by the physical therapist that performs the service.” “Intervention provided by the physical therapist or physical therapist assistant, under direction and super vision of a physical therapist, is documented, dated, and authenticated by the physical therapist who performs the service or, when permissible by the law, the physical therapy assistant.”

References

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  1. Role of Manual Therapies in Musculoskeletal Disorders. PM&R Knowledge Now. Available at: http://now.aapmr.org/rehab-essentials/special-assessment-mgmt-strategy/Pages/Role-of-Manual-Therapies-in-Musculoskeletal-Disorders.aspx. Last accessed September, 2013.
  2. Taylor NF, Dodd KJ, Shields N, Bruder A. Therapeutic exercise in physiotherapy practice is beneficial: a summary of systematic reviews 2002-2005. Aust J Physiother. 2007; 53(1):7-16.
  3. Cherkin, D.C., Sherman, K.J., Kahn, J., Wellman, R., Cook, A.J., Johnson, E., Erro, J., Delaney, 81 K., Deyo, R.A. (2011). A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial. Ann Intern Med, 155(1):1-9. Available at: http://annals.org/article.aspx?volume=155&page=1. Last accessed September, 2013.
  4. Perlman AI, Ali A, Njike VY, et al. Massage therapy for osteoarthritis of the knee: a randomized dose-finding trial. PLoS One. 2012; 7(2):e30248.
  5. Medicare Benefit Policy Manual. Comprehensive Outpatient Rehabilitation Facility. Physical Therapy. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c12.pdf. Last accessed September, 2013.
  6. American Physical Therapy Association (APTA). Guide to Physical Therapist Practice; updated: 2013. Available at: http://www.apta.org/PatientCare/. Last accessed September, 2013.
  7. National Guideline Clearinghouse. Manual medicine guidelines for musculoskeletal injuries. Available at: http://www.guideline.gov/content.aspx?id=15135. Last accessed September, 2013.
  8. Reviewed by practicing Chiropractor January 2009; January 2010; April 2011.

Coding

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Codes

Number

Description

CPT

97001

Physical therapy evaluation

 

97002

Physical therapy re-evaluation

 

97010

Application of a modality to one or more areas; hot or cold packs

 

97012

Traction, mechanical

 

97014

Electrical stimulation, unattended

 

97016

Vasopneumatic devices

 

97022

Application of a modality to one or more areas; Whirlpool (see appendix)

 

97024

Application of a modality to one or more areas; Diathermy

 

97026

Application of a modality to one or more areas; Infrared

 

97028

Application of a modality to one or more areas; Ultraviolet

 

97032

Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes

 

97033

Iontophoresis, each 15 minutes

 

97034

Contrast baths, each 15 minutes

 

97035

Ultrasound, each 15 minutes

 

97036

Hubbard tank, each 15 minutes

 

97039

Unlisted modality (specify type and time if constant attendance)

 

97110

Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

 

97112

Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

 

97113

Aquatic therapy with therapeutic exercises

 

97116

Gait training (includes stair climbing)

 

97124

Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)

 

97139

Unlisted therapeutic procedure (specify)

 

97140

Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

 

97150

Therapeutic procedure(s), group (2 or more individuals)

 

97530

Therapeutic activities, directed (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

 

97533

Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes

 

97535

Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes

 

97537

Community/work reintegration training (e.g., shopping, transportation, money management, vocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact by provider, each 15 minutes

 

97542

Wheelchair management (e.g., assessment, fitting, training) each 15 minutes

 

97750

Physical performance test or measurement (e.g., musculo-skeletal, functional capacity), with written report, each 15 minutes

 

97755

Assistive technology assessment (e.g., to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact by provider, with written report, each 15 minutes

 

97760

Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes

 

97761

Prosthetic training, upper and/or lower extremity(s), each 15 minutes

 

97762

Checkout for orthotic/prosthetic use, established patient, each 15 minutes

ICD-9 Procedure

93.11

Assisting exercise

 

93.12

Other active musculoskeletal exercise

 

93.13

Resistive exercise

 

93.14

Training in joint movements

 

93.15

Mobilization of spine

 

93.16

Mobilization of other joints

 

93.17

Other passive musculoskeletal exercise

 

93.18

Breathing exercise

 

93.19

Exercise, not elsewhere classified

 

93.21

Manual and mechanical traction

 

93.22

Ambulation and gait training

 

93.23

Fitting of orthotic device

 

93.24

Training in use of prosthetic or orthotic device

 

93.25

Forced extension of limb

 

93.26

Manual rupture of joint adhesions

 

93.27

Stretching of muscle or tendon

 

93.28

Stretching of fascia

 

93.29

Other forcible correction of deformity

 

93.31

Assisted exercise in pool

 

93.32

Whirlpool treatment

 

93.33

Other hydrotherapy

 

93.34

Diathermy

 

93.35

Other heat therapy

 

93.36

Cardiac retraining

 

93.37

Prenatal training

 

93.38

Combined physical therapy without mention of the components

 

93.39

Other physical therapy

ICD-9 Diagnosis

 

Multiple/varied

ICD-10 Diagnosis

   

ICD-9-CM

   

ICD-10-PCS
(effective 10/01/14)

   

HCPCS

G0151

Services of a physical therapist in a home or health setting, each 15 minutes

 

G0157

Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes

 

G0159

Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes

 

S9131

Physical therapy, in the home, per diem

 

S8950

Complex lymphedema therapy, each 15 minutes

Type of Service

Medical

 

Place of Service

Inpatient
Outpatient
Office
Home

 

Appendix

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N/A

History

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Date

Reason

05/05/97

Add to Therapy Section - New Policy

12/10/02

Replace Policy - Policy reviewed without literature review; new review date only.

05/13/03

Replace Policy - Policy reviewed; text deleted from Policy Guidelines; no criteria changes.

06/23/06

Update Scope and Disclaimer - No other changes.

07/10/07

New PR Policy - Policy updated with literature review; policy statement on maintenance programs added as not medically necessary. Benefit Application and codes updated. Policy changed from AR status to PR, replacing AR.8.03.02.

10/9/07

Cross References Updated - No other changes.

11/09/07

Reference added - No other changes.

05/13/08

Cross References Updated - No other changes.

08/12/08

Replace Policy - Policy updated with literature search. Policy statement updated to add the language “functional limitation or disability” under the medically necessary indication. Title updated to add “medicine and rehabilitation”. Codes and references added.

02/10/09

Replace Policy - Policy updated with literature search. Policy statement remains unchanged.

11/10/09

Cross Reference Update - No other changes.

02/09/10

Replace Policy - Policy updated with literature search. No change to policy statement.

12/21/10

Cross Reference Update - No other changes.

02/08/11

Replace Policy - Policy updated with literature search. No change to policy statement. Policy Guidelines updated, along with the Benefit Application; no change to policy statements. Reference number one removed and replaced.

05/10/11

Replace Policy - The title has been updated to include "Massage Therapy." Massage therapy has been incorporated to be part of the medically necessary policy statement when used in as part of PM&R-PT. An additional policy statement has been added indicating that massage therapy is considered not medically necessary as a stand-alone procedure; a medically necessary policy statement has been added for home-based occupational therapy and the definition of "homebound" has been added to the Policy Guidelines section. Approved with 90-hold for notification; effective date is November 9, 2011.

11/07/11

Minor Update – Clarification to policy statement that massage therapy may be considered medically necessary as the sole procedure when criteria are met. Massage therapy that is not part of a written Plan of Care remains not medically necessary.

02/27/12

Related Policies updated with 1.01.523.

10/26/12

Replace Policy. Added “Medical” to massage therapy in the title. Medical Necessity criteria moved to policy statement from policy guidelines section. Related policies revised with Chiropractic Services policy added. Revised wording of policy guidelines for clarity. Revised rationale section. References 5-8 added. Other references renumbered. Policy statement changed as noted, intent unchanged.

12/21/12

Minor update: add ARNPs and ANPs to the list of approved practitioners.

08/16/13

Replace policy. Rationale section updated based on literature review through June 2013; section reformatted for usability. Reference 2 added; others renumbered to match the reformatted rationale. Policy statement unchanged.

09/09/13

Replace policy. Removed policy requirement for submission of prescription and POC for massage therapy. Changed attending “physician” to attending “clinician with prescribing authority”. Policy guideline changed to say massage therapists are required to be licensed in most states instead of must be licensed in the state where service is performed. Changed “sessions” to “visits” to match wording in benefit booklets. Policy statement changed as noted. Update is subject to 90-day provider notification and will be effective 2/15/14.

01/21/14

Update Related Policies. Add 7.01.551.

03/17/14

Update Related Policies. Remove 1.01.523 as it was archived.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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