Name of Policy: Medical Criteria for Physical/Occupational Therapy and Osteopathic/Chiropractic Manipulative Treatment

Transcription

1 Name of Policy: Medical Criteria for Physical/Occupational Therapy and Osteopathic/Chiropractic Manipulative Treatment Policy #: 132 Latest Review Date: January 2015 Category: Administrative Policy Grade: Not Applicable Background/Definitions: As a general rule, benefits are payable under Blue Cross and Blue Shield of Alabama health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage. The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage: 1. The technology must have final approval from the appropriate government regulatory bodies; 2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes; 3. The technology must improve the net health outcome; 4. The technology must be as beneficial as any established alternatives; 5. The improvement must be attainable outside the investigational setting. Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are: 1. In accordance with generally accepted standards of medical practice; and 2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient s illness, injury or disease; and 3. Not primarily for the convenience of the patient, physician or other health care provider; and 4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient s illness, injury or disease. Page 1 of 7

2 Description of Procedure or Service: Physical therapy is the treatment of disease or injury by the use of therapeutic exercise and other interventions 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 on alleviating pain. Occupational therapy is a form of therapy involving the treatment of neuromusculoskeletal and psychological dysfunction through the use of specific tasks or goal-directed activities designed to improve the functional performance of an individual. Occupational therapy involves cognitive, perceptual, safety, and judgment evaluations and training. Osteopathic manipulative treatment is a form of manual treatment applied by a physician to eliminate or alleviate somatic dysfunction and related disorders. Chiropractic manipulative treatment (CMT) is a form of manual treatment to influence joint and neurophysiological function. These therapies/treatments may be accomplished by a variety of techniques. Policy: Physical Therapy, Occupational Therapy, Osteopathic Manipulative Treatment, and Chiropractic Manipulative Treatment meet Blue Cross and Blue Shield of Alabama s medical criteria for coverage when they are performed to meet the functional needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies, or prior therapeutic intervention and meet all the following criteria: The diagnosis is established by a physician/chiropractor/podiatrist and supports utilization of the therapy; There is documentation of objective physical and functional [strength, range of motion (ROM), mobility, and/or activities of daily living (ADL)] limitations; There is a plan of care that includes treatment services that are expected to result in improvement of these limitations in a reasonable and generally predictable period of time. The amount, frequency and duration of services must be reasonable; The services are one-to-one; The services are skilled. The services must be of a level of complexity and sophistication, or the condition of the patient must be such that the services required can be safely and effectively performed only by a qualified, licensed provider; Documented by the person rendering the services. Physical Therapy, Occupational Therapy, Osteopathic Manipulative Treatment, and Chiropractic Manipulative Treatment do not meet Blue Cross and Blue Shield of Alabama s medical criteria for coverage when the services do not ordinarily require the skills, sophistication, and full attention of a qualified provider. Page 2 of 7

3 Examples of these services are: Automatic massages, i.e., Aquamassage Application of hot and cold packs Use of exercise equipment Repetitive exercises Group therapy General supervision of exercises previously taught to the patient or patient s caregiver Services related to activities for the general good and well being of patients such as general exercise to promote overall fitness and flexibility, and activities to provide diversion or general motivation General or weighted exercise programs, and aerobic conditioning Endurance enhancing activities Services provided when the patient s expected restoration potential is insignificant in relation to the extent and duration of the therapy services required to achieve such potential Passive exercises not related to restoring specific loss of function Maintenance care. Maintenance care is defined as management of a patient who has reached pre-clinical status or maximum medical improvement where the condition is resolved or becomes stable Physical Therapy, Occupational Therapy, Osteopathic Manipulative Treatment, and Chiropractic Manipulative Treatment do not meet Blue Cross and Blue Shield of Alabama s medical criteria for coverage when the services of the physical therapist, occupational therapist, physician, or chiropractor are rendered to a patient who is related to the provider by blood or marriage or who lives in the provider s household. Physical Therapy or Occupational Therapy Treatments do not meet Blue Cross and Blue Shield of Alabama s medical criteria for coverage for the following type therapies: Spider therapy, spider cage Suit therapy Constraint induced movement therapy (refer to medical policy #188) Physical therapy modalities including but not limited to ultrasound, electrical stimulation, therapeutic exercise and soft tissue manipulation for the treatment of pelvic floor dysfunction or pelvic disorders including but not limited to the following conditions : a) Pelvic Floor Congestion b) Pelvic Floor Pain not of Spinal Origin c) Fecal Incontinence d) Urinary Incontinence (Except for patient education for therapeutic exercises if muscle spasms and muscle weakness are the underlying cause of the incontinence. Three to four visits are usually sufficient to accomplish the education.) e) Vulvodynia f) Hypersensitive Clitoris g) Dyspareunia Page 3 of 7

4 h) Prostatitis i) Pelvic Floor Relaxation Disorders j) Cystourethrocele k) Enterocele l) Rectocele Biofeedback is not covered for any condition under most contracts and transcutaneous electrical nerve stimulation (TENS) is not covered as a routine modality of physical therapy. The initial patient education would be a covered physical therapy service. For additional, specific coverage information please refer to the Participating Chiropractor Manual, Preferred Occupational Therapist Manual, and Preferred Physical Therapist Manual under the Provider Services section of *Note: For members ages birth through nine (9) in the State of Alabama, please refer to the member s Summary Plan Description for any Autism or Autism Spectrum Disorder (ASD) Benefits for Physical and Occupational Therapy. **Note: There are varying benefit plans for these services. Please verify benefits prior to applying policy criteria, as benefit coverage will supersede this policy. Blue Cross and Blue Shield of Alabama does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. Blue Cross and Blue Shield of Alabama administers benefits based on the member s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination. Key Points: Not applicable Key Words: Physical therapy, PT, Occupational therapy, OT, Osteopathic manipulation, Chiropractic manipulation, CMT, Spinal manipulation, athletic trainers, exercise physiologists, massage therapist, certified strength trainers, aquamassage, automatic massage, automatic body profiler, spider therapy, suit therapy, constraint induced movement therapy, pelvic floor congestion, pelvic floor pain, fecal incontinence, urinary incontinence, vulvodynia, hypersensitive clitoris, dyspareunia, prostatitis, pelvic floor relaxation, cystourethrocele, enterocele, rectocele Approved by Governing Bodies: Not applicable Page 4 of 7

5 Benefit Application: Coverage is subject to member s specific benefits. Group specific policy will supersede this policy when applicable. In general, Blue Cross and Blue Shield of Alabama contracts do not have coverage for occupational therapy services other than hand therapy. Please refer to the member s Summary Plan Description (SPD) for covered benefits. ITS: Home Policy provisions apply FEP contracts: Special benefit consideration may apply. Refer to member s benefit plan. *Note: For members ages birth through nine (9) in the State of Alabama, please refer to the member s Summary Plan Description for any Autism or Autism Spectrum Disorder (ASD) Benefits for Physical and Occupational Therapy. **Note: There are varying benefit plans for these services. Please verify benefits prior to applying policy criteria, as benefit coverage will supersede this policy. Coding: CPT codes: Physical Medicine and Rehabilitation Osteopathic Manipulative Treatment Chiropractic Manipulative Treatment References: 1. American Occupational Therapy Association. Guidelines for supervision, roles, and responsibilities during the delivery of occupational therapy services. Am J Occup Therapy. 2004; 58(6): American Physical Therapy Association. Access to, admission to, and patient/client rights within physical therapy services. Available at: 3. American Physical Therapy Association. Guide to Physical Therapist Practice. 2 nd Edition revised. American Physical Therapy Association. January Originally published as: Guide to Physical Therapist Practice. Phys Ther. 2001; 81: American Physical Therapy Association. Physical Therapy and the Older Adult. Available at: 5. American Physical Therapy Association. Provision of Physical Therapy Interventions and Related Tasks. Available at: 6. American Physical Therapy Association. Reimbursement for Physical Therapy Services. Available at: Page 5 of 7

6 7. American Physical Therapy Association. Standards of Practice for Physical Therapy. Available at: 8. Foruzandeh N, Parvin N. Occupational therapy for inpatients with chronic schizophrenia: a pilot randomized controlled trial. Jpn J Nurs Sci Jun; 10(1): Kim SY, Yoo EY, Jung MY et al. A systematic review of the effects of occupational therapy for persons with dementia: A meta-analysis of randomized controlled trials. NeuroRehabilitaion. 2012; 31(2): Legg LA, Drummond AE, Langhorne P. Occupational therapy for patients with problems in activities of daily living after stroke. Cochrane Database Syst Rev. 2006;(4):CD Miller EL, Murray L, Richards L, et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke. 2010;41(10): Moyers PA. The guide to occupational therapy practice. American Occupational Therapy Association. Am J Occup Ther. 1999; 53(3): NIH Consensus Statement. Rehabilitation of persons with traumatic brain injury Oct 26-28; 16(1):1-41. Available at: Reitz SM, Austin DJ, Brandt LC, et al. Guidelines to the Occupational Therapy Code of Ethics. Am J Occup Ther. 2006; 60(6): Sneed RC, May WL, Stencel C. Physicians' reliance on specialists, therapists, and vendors when prescribing therapies and durable medical equipment for children with special health care needs. Pediatrics. 2001; 107(6): Steultjens EM, Dekker JJ, Bouter LM, et al. Evidence of the efficacy of occupational therapy in different conditions: an overview of systematic reviews. Clin Rehabil. 2005; 19(3): Steultjens EM, Dekker JJ, Bouter LM, et al. Occupational therapy for rheumatoid arthritis. Cochrane Database of Syst Rev. 2004;(1):CD Sturkenboom IH, Graff MJ, et al. Efficacy of occupational therapy for patients with parkinson s disease: a randomised controlled trial. Lancet Neruol Jun; 13(6): Policy History: Medical Policy Group, 1990 Policy and Benefit Committee, December 1999 Policy and Benefit Committee, January 2000 Medical Policy Group, April 2000 Medical Policy Group, May 2000 Policy and Benefit Committee, September 2000 Medical Policy Group, January 2001 Medical Policy Group, August 2003 (2) Medical Policy Administration Committee, August 2003 Available for comment September 8-October 22, 2003 Medical Policy Group, February 2007 (3) Medical Policy Administration Committee, February 2007 Page 6 of 7

7 Available for comment March 1-April 14, 2007 Medical Policy Group, October 2009 (3) Medical Policy Administration Committee, October 2009 Available for comment October 20-November 5, 2009 Medical Policy Group, November 2009 Medical Policy Administration Committee, November 2009 Available for comment November 6-December 21, 2009 Medical Policy Group, January 2015 (3): 2015 Update References and Approved Governing Bodies; no change in policy statement. Added statements to Policy and Approved Governing Bodies sections regarding autism/asd benefits and varying benefit plans for these services. This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a caseby-case basis according to the terms of the member s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment. This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield s administration of plan contracts. Page 7 of 7