Description

OT is the treatment of neuromusculoskeletal and psychological dysfunction, caused by disease, trauma, congenital anomaly, or prior therapeutic process, through the use of specific tasks or goal-directed activities designed to improve functional performance of the individual. OT services emphasize useful and purposeful activities to improve neuromusculoskeletal function and to provide training in activities of daily living (ADL).

Criteria

OT may be considered medically necessary for individuals who meet ALL of the following criteria:

• The therapy is aimed at improving, adapting or restoring functions of an individual who has been impaired or permanently lost as a result of physical disability due to illness, injury, congenital anomaly, or prior therapeutic intervention; and
• Achieve a specific diagnosis-related goal for an individual who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time based on the qualified OT assessment of the individual’s restoration potential and unique medical condition; and
• Specific, effective and reasonable treatment for the individual’s diagnosis and physical condition; and
• The services are delivered by a qualified provider of OT services. A qualified provider is an individual who is licensed, where required, and performs within the scope of licensure.

A typical treatment plan consists of up to one (1) hour sessions and up to four (4) physical medicine procedures per date of service and includes ANY of the following:

• Modalities; or
• Therapeutic procedures; or
• Tests and measurements; or
• Muscle range of motion (ROM) testing; or
• Orthotic management and prosthetic management.

Exceptions include [standardized cognitive performance testing per hour and work hardening/conditioning; initial two (2) hours. Each additional hour of work hardening/conditioning will be considered exceeding the limitation; and is considered not medically necessary.

Duplicate therapy is considered not medically necessary. Example: An individual receiving therapy services from two (2) different providers treating the same condition.

Procedure Codes

Maintenance Therapy

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.

A maintenance program consists of activities that preserve the individual’s present level of function and prevent regression of that function. These services would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness.

Maintenance therapy may be reported under physical or manipulative therapy performed for maintenance rather than restoration, and unless the individual has habilitative services benefits.

Procedure Codes

Habilitative Therapy

Habilitative therapy services are ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury. This includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies. Habilitative therapy is not eligible for reimbursement, unless the member has a habilitative benefit.

• Spinal manipulation is not considered a habilitative service.

Procedure Codes

Sensory Integrative Techniques

When the member's benefit includes coverage for ASD; sensory integration is a covered service only for those individuals diagnosed with ASD. Sensory integrative techniques as distinct and definable components of the rehabilitation process are considered experimental/investigational and, therefore, noncovered when used to treat any other conditions. Scientific evidence does not demonstrate the efficacy of these services for other conditions.

Procedure Codes

Taping Techniques

Taping Techniques (examples include, but are not limited to, Kinesio® Taping (kinesiology), McConnell taping techniques) are considered experimental/investigational and, therefore, non-covered. There is a lack of clinical studies showing that taping techniques to be effective.

Procedure Codes

Diagnosis Codes

Coverage Diagnosis Codes for Procedure Code 97533

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 removed related reimbursement language

4-1-2020 Added the following Procedure codes 97165, 97166, 97167, 97168, 97597 and 97598.

Links

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.