Physical Therapy (PT)

Policy ID: Y-1-065

Section: Therapy

Effective Date: July 01, 2018

Revised Date: March 18, 2024

Revision Effective Date: May 06, 2024

Last Reviewed: March 19, 2024

Applies To: Commercial and Medicaid Expansion

Description

Physical medicine and rehabilitation is a medical specialty concerned with diagnosis, evaluation, and management of persons with physical impairment and disability. This specialty involves diagnosis and treatment of individuals with painful or functionally limiting conditions, the management of comorbidities and co-impairments.

Criteria

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

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Physical medicine is considered medically necessary when ALL of the following criteria are met;

Expectation of restoring the individual's level or function that has been lost or reduced by injury or illness; and
Treatment plans must be maintained in the medical record and available upon request.

Procedure Codes

4018F

90901

95851

95852

95992

96125

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97035

97036

97039

97110

97112

97113

97116

97124

97129

97130

97139

97140

97150

97161

97162

97163

97164

97530

97533

97535

97537

97542

97545

97546

97597

97598

97750

97755

97760

97761

97763

97799

99374

99375

99377

99378

99380

G0181

G0182

G0237

G0238

G0239

G0283

S8948

S8950

S9123

S9124

S9125

S9128

S9129

S9131

T1021

T1025

T1026

Maintenance Therapy

Physical medicine services performed repetitively to maintain a level of function are not eligible for coverage unless the member has Habilitative services benefits.

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 begins when the therapeutic goals of a treatment plan have been achieved, and no additional functional progress is apparent or expected to occur.

Procedure Codes

S8990

Habilitative Therapy

Habilitative therapy services may be considered medically necessary when the following criteria are met:

Ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury; and/or

Includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.

Note:

Habilitative therapy is not eligible for payment unless the member has a habilitative benefit.

*Spinal manipulation is not considered a habilitative service

Habilitative services not meeting the criteria as outlined in this policy are considered not medically necessary.

Procedure Codes

4018F

90901

95851

95852

95992

96125

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97035

97036

97039

97110

97112

97113

97116

97124

97129

97130

97139

97140

97150

97161

97162

97163

97164

97530

97533

97535

97537

97542

97545

97546

97597

97598

97750

97755

97760

97761

97763

97799

99374

99375

99377

99378

99380

G0181

G0182

G0237

G0238

G0239

G0283

S8948

S8950

S9123

S9124

S9125

S9128

S9129

S9131

T1021

T1025

T1026

Supervised Modalities

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

Procedure Codes

97012

97014

97016

97018

97022

97024

97026

Vasopneumatic Compression

Vasopneumatic compression is considered medically necessary for the following conditions;

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

Vasopneumatic compression not meeting the criteria as indicated in this policy is considered not medically necessary.

Vasopneumatic compression 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.

Procedure Code

97016

Infrared Therapy

The use of infrared and near-infrared light and heat, including monochromatic infrared energy, 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 is considered not medically necessary.

Procedure Code

97026

Constant Attendance Modalities

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

When two (2) constant attendance modalities are performed at the same time, using one device, the code representing the primary modality must be reported.

Procedure Codes

97032

97033

97034

97035

97036

97039

Aquatic Therapy

Aquatic therapy must be performed with the expectation of restoring an individuals 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.

A provider must have direct (one to one) individual contact with the individual 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 individual can be reasonably expected to accomplish through the aquatic therapy program and the specific methods chosen.

Procedure Codes

97034

97113

Gait Training

Gait training may be considered medically necessary for the following indications:

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

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

Gait training not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

97116

97760

97761

97763

Vestibular Rehabilitation Therapy

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

A vestibular rehabilitation program may be considered medically necessary for individuals 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); or
Mixed {peripheral and central vestibular disorders; or
Central causes of vertigo (e.g., CVA, multiple sclerosis, and mild traumatic brain injury).

A vestibular rehabilitation program not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Code

S9476

The following services are considered experimental/investigational and, therefore, non-covered, because the safety and effectiveness of this service cannot be established by published peer-reviewed literature. This is not an all inclusive list:

Equestrian/Hippotherapy
Low-Level Laser Therapy (Cold Laser Therapy)

Procedure Codes

S8940

S8948

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.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code: 97016

I87.2

I87.8

I87.9

I89.0

I97.2

M79.81

M79.89

Q82.0

R60.0

R60.1

R60.9

S70.10XA

S70.11XA

S70.12XA

S80.10XA

S80.11XA

S80.12XA

Covered Diagnosis Codes for Procedure Code: 97116

M51.27

R26.9

R62.50

S98.111A

S98.111D

S98.111S

S98.112A

S98.112D

S98.112S

S98.121A

S98.121D

S98.121S

S98.122A

S98.122D

S98.122S

S98.131A

S98.131D

S98.131S

S98.132A

S98.132D

S98.132S

S98.141A

S98.141D

S98.141S

S98.142A

S98.142D

S98.142S

S98.211A

S98.211D

S98.211S

S98.212A

S98.212D

S98.212S

S98.221D

S98.221S

S98.222A

S98.222D

S98.222S

Z96.641

Z96.642

Z96.643

Z96.649

Z96.651

Z96.652

Z96.653

Z96.659

Z96.661

Z96.662

Z96.669

Covered Diagnosis Codes for Procedure Code: S9476

G35

H81.10

H81.11

H81.12

H81.13

H81.20

H81.21

H81.22

H81.23

H81.311

H81.312

H81.313

H81.319

H81.391

H81.392

H81.393

H81.399

H81.4

H83.01

H83.02

H83.03

H83.09

I63.30

I63.311

I63.312

I63.313

I63.321

I63.322

I63.323

I63.329

I63.331

I63.332

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020

Updated language

Internal Medical Policy Committee 3-17-2021 Revision updated language and coding update

Added procedure code: S8940.

Internal Medical Policy Committee 3-23-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 7-21-2022 Revision with coding updates - Effective September 05, 2022

Removed procedure codes: 97165; 97166; 97167; 97168; and S8990
Added procedure codes: 4018F; 90901; 96125; 97129; 97130; 97545; 97546; 97755; 99339; 99340;99374; 99375; 99377; 99378; 99380; G0181; G0182; G0237; G0238; G0239; S9123; S9124; S9125; S9128; S9129; S9131; T1021; T1025; T1026.

Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 02, 2022

Removed procedure codes 99339; 99340; and
Added procedure codes 97597; and 97598.

Internal Medical Policy Committee 5-23-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 11-15-2023 Coding update- Effective January 01, 2024

Added diagnosis codes R26.9 and R62.50 for procedure code 97116.

Internal Medical Policy Committee 3-19-2024 Revision- Effective May 06, 2024

Revised criteria; and
Added Policy Application; and
Added procedure code 97116.

Links

References (PDF)

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.

Policy ID: Y-1-064

Section: Therapy

Effective Date: July 01, 2018

Revised Date: November 11, 2023

Revision Effective Date: January 01, 2024

Last Reviewed: November 15, 2023

Archived Date: May 05, 2024

Applies To: Commercial and Medicaid Expansion

Description

Criteria

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 individual'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.

Services exceeding the limitation will be considered not medically necessary.

Duplicate therapy is considered not medically necessary.

Procedure Codes

4018F

90901

95851

95852

95992

96125

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97035

97036

97039

97110

97112

97113

97116

97124

97129

97130

97139

97140

97150

97161

97162

97163

97164

97530

97533

97535

97537

97542

97545

97546

97597

97598

97750

97755

97760

97761

97763

97799

99374

99375

99377

99378

99380

G0181

G0182

G0237

G0238

G0239

G0283

S8948

S8950

S9123

S9124

S9125

S9128

S9129

S9131

T1021

T1025

T1026

Maintenance Therapy

Physical medicine services performed repetitively to maintain a level of function are not eligible for coverage unless the member has Habilitative services benefits.

Maintenance begins when the therapeutic goals of a treatment plan have been achieved, and no additional functional progress is apparent or expected to occur.

Procedure Code

S8990

Habilitative Therapy

Habilitative therapy services 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.

*Spinal manipulation is not considered a habilitative service.

Procedure Codes

4018F

90901

95851

95852

95992

96125

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

97035

97036

97039

97110

97112

97113

97116

97124

97129

97130

97139

97140

97150

97161

97162

97163

97164

97530

97533

97535

97537

97542

97545

97546

97597

97598

97750

97755

97760

97761

97763

97799

99374

99375

99377

99378

99380

G0181

G0182

G0237

G0238

G0239

G0283

S8948

S8950

S9123

S9124

S9125

S9128

S9129

S9131

T1021

T1025

T1026

Supervised Modalities

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

Procedure Codes

97012

97014

97016

97018

97022

97024

97026

Vasopneumatic Compression

Vasopneumatic compression is considered medically necessary for the following conditions;

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

Vasopneumatic compression not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Code

97016

Infrared Therapy

Procedure Code

97026

Constant Attendance Modalities

When two (2) constant attendance modalities are performed at the same time, using one device, the code representing the primary modality must be reported.

Procedure Codes

97032

97033

97034

97035

97036

97039

Aquatic Therapy

A provider must have direct (one to one) individual contact with the individual when reporting aquatic therapy.

Procedure Codes

97034

97113

Gait Training

Gait training may be considered medically necessary for the following indications:

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

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

Gait training not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

97760

97761

97763

Vestibular Rehabilitation Therapy

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

A vestibular rehabilitation program may be considered medically necessary for individuals 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); or
Mixed {peripheral and central vestibular disorders; or
Central causes of vertigo (e.g., CVA, multiple sclerosis, and mild traumatic brain injury).

A vestibular rehabilitation program not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Code

S9476

Equestrian/Hippotherapy
Low-Level Laser Therapy (Cold Laser Therapy)

Procedure Codes

S8940

S8948

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code: 97016

I87.2

I87.8

I87.9

I89.0

I97.2

M79.81

M79.89

Q82.0

R60.0

R60.1

R60.9

S70.10XA

S70.11XA

S70.12XA

S80.10XA

S80.11XA

S80.12XA

Covered Diagnosis Codes for Procedure Code: 97116

M51.27

R26.9

R62.50

S98.111A

S98.111D

S98.111S

S98.112A

S98.112D

S98.112S

S98.121A

S98.121D

S98.121S

S98.122A

S98.122D

S98.122S

S98.131A

S98.131D

S98.131S

S98.132A

S98.132D

S98.132S

S98.141A

S98.141D

S98.141S

S98.142A

S98.142D

S98.142S

S98.211A

S98.211D

S98.211S

S98.212A

S98.212D

S98.212S

S98.221D

S98.221S

S98.222A

S98.222D

S98.222S

Z96.641

Z96.642

Z96.643

Z96.649

Z96.651

Z96.652

Z96.653

Z96.659

Z96.661

Z96.662

Z96.669

Covered Diagnosis Codes for Procedure Code: S9476

G35

H81.10

H81.11

H81.12

H81.13

H81.20

H81.21

H81.22

H81.23

H81.311

H81.312

H81.313

H81.319

H81.391

H81.392

H81.393

H81.399

H81.4

H83.01

H83.02

H83.03

H83.09

I63.30

I63.311

I63.312

I63.313

I63.321

I63.322

I63.323

I63.329

I63.331

I63.332

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020

Updated language

Internal Medical Policy Committee 3-17-2021 Revision updated language and coding update

Added procedure code: S8940.

Internal Medical Policy Committee 3-23-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 7-21-2022 Revision with coding updates - Effective September 05, 2022

Removed procedure codes: 97165; 97166; 97167; 97168; and S8990
Added procedure codes: 4018F; 90901; 96125; 97129; 97130; 97545; 97546; 97755; 99339; 99340;99374; 99375; 99377; 99378; 99380; G0181; G0182; G0237; G0238; G0239; S9123; S9124; S9125; S9128; S9129; S9131; T1021; T1025; T1026

Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 02, 2022

Removed procedure codes 99339 and 99340
Added procedure codes 97597 and 97598

Internal Medical Policy Committee 5-23-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 11-15-2023 Coding update- Effective January 01, 2024

Added diagnosis codes R26.9 and R62.50 for procedure code 97116.

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