REHABILITATION SERVICES (OUTPATIENT) Protocol: MSC028 Effective Date: March 1, 2016 Table of Contents Page COMMERCIAL COVERAGE RATIONALE... 1 DEFINITIONS... 2 APPLICABLE CODES... 4 REFERENCES... 7 POLICY HISTORY/REVISION INFORMATION... 7 INSTRUCTIONS FOR USE This protocol provides assistance in interpreting UnitedHealthcare benefit plans. When deciding coverage, the enrollee specific document must be referenced. The terms of an enrollee's document (e.g., Certificate of Coverage (COC) or Evidence of Coverage (EOC)) may differ greatly. In the event of a conflict, the enrollee's specific benefit document supersedes this protocol. All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this Protocol. Other Protocols, Policies and Coverage Determination Guidelines may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Protocols, Policies and Guidelines as necessary. This protocol is provided for informational purposes. It does not constitute medical advice. This policy does not govern Medicare Group Retiree members. UnitedHealthcare may also use tools developed by third parties, such as the MCG Care Guidelines, to assist us in administering health benefits. The MCG Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. COMMERCIAL COVERAGE RATIONALE Indications for Coverage Short-Term Rehabilitation therapy Covered Services include: Speech therapy. Occupational therapy. Physical therapy on an Inpatient or outpatient basis when ordered by the Member s PCP and authorized by HPN s Managed Care Program. Benefits for rehabilitation therapy are limited to services given for acute or recently acquired conditions that, in the judgment of the Member's PCP and HPN s Managed Care Program, are subject to significant improvement through Short-Term therapy. Covered Services do not include cardiac rehabilitation services provided on a non-monitored basis nor do they include treatment for mental retardation. Rehabilitation Services (Outpatient) Page 1 of 7
DEFINITIONS Alternate Facility: A health care facility that is not a Hospital and that provides one or more of the following services on an outpatient basis, as permitted by law: Surgical services Emergency Health Services Rehabilitative, laboratory, diagnostic or therapeutic services Cardiac Rehabilitation: A medically supervised, exercise-based program in which patients with certain cardiac conditions, examples include but are not limited to: an acute myocardial infarction within last 12 months; a coronary bypass surgery; current stable angina pectoris; heart valve repair or replacement; percutaneous transluminal coronary angioplasty [PTCA] or coronary stenting; or a heart or heart-lung transplant) are prescribed a regimen of physical exercise. The primary intent is to improve the functional capacity of the heart and provide the necessary skills for self-monitoring of unsupervised exercise. Components of a Cardiac rehabilitation may include: Cardiac risk factor modification, including education, counseling and behavioral intervention that are tailored to patient s individual needs; psychosocial assessment, outcomes assessment and an individual treatment plan. Cognitive Rehabilitation: Cognitive rehabilitation involves therapies designed to help improve damaged cognitive functions such as attention, memory and learning, affect and expression, problemsolving, and executive function. Experimental or Investigational Service(s): Medical, surgical, diagnostic, psychiatric, mental health, substance-related and addictive disorders or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time we make a determination regarding coverage in a particular case, are determined to be any of the following: Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use. Subject to review and approval by any institutional review board for the proposed use. (Devices which are FDA approved under the Humanitarian Use Device exemption are not considered to be Experimental or Investigational.) The subject of an ongoing clinical trial that meets the definition of a Phase I, II or III clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight. Exceptions: Clinical trials for which Benefits are available as described under Clinical Trials in Section 1: Covered Health Services. If you are not a participant in a qualifying clinical trial, as described under Clinical Trials in Section 1: Covered Health Services, and have a Sickness or condition that is likely to cause death within one year of the request for treatment we may, in our discretion, consider an otherwise Experimental or Investigational Service to be a Covered Health Service for that Sickness or condition. Prior to such a consideration, we must first establish that there is Rehabilitation Services (Outpatient) Page 2 of 7
sufficient evidence to conclude that, albeit unproven, the service has significant potential as an effective treatment for that Sickness or condition. Habilitative Services: Occupational therapy, physical therapy and speech therapy prescribed by the Member's treating Physician pursuant to a treatment plan to develop a function not currently present as a result of a congenital, genetic, or early acquired disorder. A "congenital or genetic disorder" includes, but is not limited to, hereditary disorders. An "early acquired disorder" refers to a disorder resulting from Sickness, Injury, trauma or some other event or condition suffered by a Member prior to that Member developing functional life skills such as, but not limited to, walking, talking, or self-help skills. Physician: Anyone qualified and licensed to practice medicine and surgery by the state where the practice is located who has the degree of Doctor of Medicine (MD) or Doctor of Osteopathy (DO). Physician also means Doctor of Dentistry, a Doctor of Podiatric Medicine or a Chiropractor when they are acting within the scope of their license. Pulmonary Rehabilitation: An individualized multidisciplinary and comprehensive intervention for patients with chronic respiratory dysfunction who are symptomatic, who may have had an acute exacerbation, and who often have a decreased ability to participate in activities of daily living. Underlying conditions vary, and may include obstructive (emphysema, chronic bronchitis) or restrictive (pulmonary fibrosis) pulmonary disease, neuromuscular disease, or lung cancer, as well as patients pre- or post-transplant or lung volume reduction surgery patients. Rehabilitation Services - Outpatient Therapy: Short-term outpatient rehabilitation services, limited to: Physical therapy. Occupational therapy. Manipulative Treatment. Speech therapy. Pulmonary rehabilitation therapy. Cardiac rehabilitation therapy. Post-cochlear implant aural therapy. Cognitive rehabilitation therapy. Rehabilitation services must be performed by a Physician or by a licensed therapy provider. Benefits under this section include rehabilitation services provided in a Physician's office or on an outpatient basis at a Hospital or Alternate Facility. Benefits can be denied or shortened for Covered Persons who are not progressing in goal- directed rehabilitation services or if rehabilitation goals have previously been met. Not Medically Necessary Service(s): Services, including medications, that are determined not to be effective for treatment of the medical condition and/or not to have a beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature. Rehabilitation Services (Outpatient) Page 3 of 7
Well-conducted randomized controlled trials. (Two or more treatments are compared to each other, and the patient is not allowed to choose which treatment is received.) Well-conducted cohort studies from more than one institution. (Patients who receive study treatment are compared to a group of patients who receive standard therapy. The comparison group must be nearly identical to the study treatment group.) We have a process by which we compile and review clinical evidence with respect to certain health services. From time to time, we issue medical and drug policies that describe the clinical evidence available with respect to specific health care services. These medical and drug policies are subject to change without prior notice. You can view these policies at www.myuhc.com. Please note: If you have a life-threatening Sickness or condition (one that is likely to cause death within one year of the request for treatment) we may, in our discretion, consider an otherwise Unproven Service to be a Covered Health Service for that Sickness or condition. Prior to such a consideration, we must first establish that there is sufficient evidence to conclude that, albeit unproven, the service has significant potential as an effective treatment for that Sickness or condition. Work Hardening: Work hardening is an interdisciplinary program consisting of physical therapy, occupational therapy and counseling professionals for injured workers or other adults whose injuries or disease processes interfere with their ability to work. It provides structured treatment designed to progressively improve physical function as a transition between acute care and return to work. APPLICABLE CODES The Current Procedural Terminology (CPT ) codes and Healthcare Common Procedure Coding System (HCPCS) codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the enrollee specific benefit document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Other policies and coverage determination guidelines may apply. This list of codes may not be all inclusive. CPT /HCPCS Code Description Physical Therapy 64550 Application of surface (transcutaneous) neurostimulator 97001 Physical therapy evaluation 97002 Physical therapy reevaluation 97012 Application of a modality to 1 or more areas; traction, mechanical 97016 Application of a modality to 1 or more areas; vasopneumatic devices 97018 Application of a modality to 1 or more areas; paraffin bath 97022 Application of a modality to 1 or more areas; whirlpool Application of a modality to 1 or more areas; diathermy (e.g., 97024 microwave) 97026 Application of a modality to 1 or more areas; infrared 97028 Application of a modality to 1 or more areas; ultraviolet Application of a modality to one or more areas; electrical stimulation Rehabilitation Services (Outpatient) Page 4 of 7
97032 (manual), each 15 Application of a modality to one or more areas; iontophoresis, each 97033 15 Application of a modality to one or more areas; contrast baths, each 97034 15 Application of a modality to one or more areas; ultrasound, each 15 97035 Application of a modality to one or more areas; hubbard tank, each 15 97036 Therapeutic procedure, one or more areas, each 15 ; 97110 therapeutic exercises to develop strength and endurance, range of motion and flexibility Neuromuscular reeducation of movement, balance, coordination, 97112 kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Therapeutic procedure, one or more areas, each 15 ; aquatic 97113 therapy with therapeutic exercises Therapeutic procedure, one or more areas, each 15 ; gait 97116 training (includes stair climbing) Manual therapy techniques (e.g., mobilization/manipulation, manual 97140 lymphatic drainage, manual traction), one or more regions, each 15 97150 Therapeutic procedure(s), group (2 or more individuals) Therapeutic activities, direct (one-on-one) patient contact (use of 97530 dynamic activities to improve functional performance), each 15 97542 Wheelchair management/propulsion training, each 15 Physical performance test or measurement, w/ written report, each 15 97750 Orthotic(s) management and training (including assessment and 97760 fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 97761 Prosthetic training, upper and/or lower extremity(s), each 15 Checkout for orthotic/prosthetic use, established patient, each 15 97762 G0283 Electrical stimulation (unattended) to one or more areas for indication (s) other than wound care, as part of a therapy plan of care S8948 Application of a modality (requiring constant provider attendance) to one or more areas; low level laser; each 15 S9476 Vestibular rehabilitation program, non physician provider, per diem V5364 Dysphagia screening Occupational Therapy 97003 Occupational therapy evaluation 97004 Occupational therapy reevaluation 97018 Application of a modality to one/more areas: paraffin bath Therapeutic procedure, one or more areas, each 15 ; Rehabilitation Services (Outpatient) Page 5 of 7
97110 therapeutic exercises to develop strength and endurance, range of motion and flexibility Therapeutic proc, one/more areas; 15 mins: gait training (including stair 97116 climbing) Therapeutic activities, direct (one on one) patient contact by the 97530 provider (use of dynamic activities to improve functional performance), each 15 Self-care/home management training (e.g., activities of daily living (adl) and compensatory training, meal preparation, safety procedures, and 97535 instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 97542 Wheelchair management/propulsion training, each 15 Assistive technology assessment (e.g., to restore, augment or compensate for existing function, optimize functional tasks and/or maximize 97755 environmental accessibility), direct one-on-one contact, with written report, each 15 Cardiac Rehabilitation Physician or other qualified health care professional services for 93797 outpatient cardiac rehabilitation; without continuous ECG monitoring (per session) Physician or other qualified health care professional services for 93798 outpatient cardiac rehabilitation; with continuous ECG monitoring (per session) Intensive cardiac rehabilitation; with or without continuous ECG G0422 monitoring with exercise, per session Intensive cardiac rehabilitation; with or without continuous ECG G0423 monitoring without exercise, per session S9472 Cardiac rehabilitation program, non-physician provider, per diem Pulmonary Rehabilitation Therapeutic procedures to increase strength or endurance of respiratory G0237 muscles, face-to face, one-on-one, per 15 (includes monitoring) Therapeutic procedures to improve respiratory function, other than G0238 prescribed by g0237, face-to face, one-on-one, each 15 (includes monitoring) Therapeutic procedures to improve respiratory function or increase G0239 strength or endurance of respiratory muscles, two or more individuals (includes monitoring) Preoperative pulmonary surgery services for preparation for lvrs, G0302 complete course of services, to include a minimum of 16 days of service Preoperative pulmonary surgery services for preparation for lvrs, 10 to G0303 15 days of services Preoperative pulmonary surgery services for preparation for lvrs, 1 to 9 G0304 days of services Postdischarge pulmonary surgery services after lvrs, minimum of 6 days G0305 of services Pulmonary rehabilitation, including exercise (includes monitoring), one G0424 hour, per session, up to 2 sessions per day Rehabilitation Services (Outpatient) Page 6 of 7
S9473 Cognitive Rehabilitation 97532 Pulmonary rehabilitation non-physician provider per diem Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one on one) patient contact, each 15 Aural Rahabilitation 92626 Evaluation of auditory rehabilitation status; first hour Evaluation of auditory rehabilitation status; each additional 15 92627 (list separately in addition to code for primary procedure) 92630 Auditory rehabilitation; pre-lingual hearing loss 92633 Auditory rehabilitation; post-lingual hearing loss Manipulative Treatment 98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved 98926 Osteopathic manipulative treatment (OMT); 3-4 body regions involved 98927 Osteopathic manipulative treatment (OMT); 5-6 body regions involved 98928 Osteopathic manipulative treatment (OMT); 7-8 body regions involved Osteopathic manipulative treatment (OMT); 9-10 body regions involved 98929 98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions 98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions 98942 Chiropractic manipulative treatment (CMT); spinal, 5 regions 98943 REFERENCES Health Plan of Nevada, Evidence of Coverage, 2016 POLICY HISTORY/REVISION INFORMATION Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions CPT is a registered trademark of the American Medical Association. Date Action/Description 01/27/2016 Corporate Medical Affairs Committee The foregoing Health Plan of Nevada/Sierra Health & Life Healthcare Operations protocol has been adopted from an existing UnitedHealthcare coverage determination guideline that was researched, developed and approved by the UnitedHealthcare Coverage Determination Committee. Rehabilitation Services (Outpatient) Page 7 of 7