Latest Review Date: September 2024

Category: Administrative        

Note: Coverage may be subject to legislative mandates, including but not limited to the following, which apply prior to the policy statements:

Federal Women's Health and Cancer Rights Act (WHCRA)

In accordance with the mandate listed above, Physical/Occupational Therapy services are covered when used to treat lymphedema resulting from a mastectomy and ordered by the individual’s treating physician.

POLICY:

Rehabilitative and Habilitative Physical Therapy and Occupational Therapy may be considered medically necessary 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; AND

• There is documentation of objective physical and functional [strength, range of motion (ROM), mobility, and/or activities of daily living (ADL)] limitations; AND

• There is an individualized plan of care that includes treatment services that are expected to result in restoring or acquiring function in a reasonable and generally predictable period of time as short-term therapy, usually within a three month period.  The amount, frequency and duration of services must be reasonable; AND

• The services are one-to-one; AND

• 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; AND

• Documented by the person rendering the services; AND

• The services must not duplicate services provided by any other therapy.

Rehabilitative and Habilitative Physical Therapy and Occupational Therapy is considered not medically necessary when the services do not ordinarily require the skills, sophistication, and full attention of a qualified provider. 

Examples of these services include but are not limited to:

• Automatic massages, i.e., Aquamassage

• Application of hot and cold packs

• Use of exercise equipment  (including Functional Electrical Stimulation (FES) cycle ergometer devices) 

• 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

**For functional electrical stimulation (FES) cycle ergometer devices, refer to MP#358 Functional Neuromuscular Electrical Stimulation

Rehabilitative and Habilitative Physical Therapy or Occupational Therapy Treatments are considered not medically necessary for the following type therapies:

• Spider therapy, spider cage

• Suit therapy

• Constraint induced movement therapy (refer to medical policy #188)

Rehabilitative and Habilitative Physical Therapy and Occupational Therapy is considered not medically necessary when the services of the physical therapist, occupational therapist, physician or other healthcare provider are rendered to a patient who is related to the provider by blood or marriage or who lives in the provider’s household.

NOTE: Biofeedback is not covered for any condition under most contracts and electrical nerve stimulation (e.g. e-stim, TENS) is not covered as a routine modality of therapy. The initial patient education would be a covered physical therapy service.

For additional, specific coverage information please refer to the Preferred Occupational Therapist Manual and Preferred Physical Therapist Manual under the Provider Services section of www.bcbsal.org.

* NOTE: Please refer to the member’s Summary Plan Description for any Autism, or Autism Spectrum Disorder (ASD), and/or Applied Behavioral Analysis (ABA) Benefits. There are varying benefit plans for these services. Please verify benefits prior to applying policy criteria, as benefits will supersede this policy.

DESCRIPTION OF PROCEDURE OR SERVICE:

Rehabilitation therapy is defined as services “provided to help a person regain, maintain, or prevent deterioration of a skill or function that has been acquired but then was lost or impaired due to illness, injury, or disabling condition.” An example of this would be skills lost due to a stroke.

Rehabilitation services should assist patients in restoring a necessary skill or function that would impact activities of daily living (ADLs).

Habilitation therapy is defined as services or devices “to attain, maintain, or prevent deterioration of a skill or function never learned or acquired due to a disabling condition.” An example would be a child not walking by the expected age.

Habilitation services should assist patients in acquiring (versus restoring) a necessary skill or function that would impact activities of daily living (ADLs).

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.

These therapies/treatments may be accomplished by a variety of techniques.

KEY POINTS:

The Department of Health and Human Services has issued a Final Rule as a provision of Essential Health Benefits (EHB) (section 156.115) of the Patient Protection & Affordable Care Act (OPACA) (section 1302(b)(1)(G)) that rehabilitative and habilitative services be one of the ten categories of essential health benefits. Effective for plan years beginning January 1, 2017, separate limits on rehabilitative and habilitative services are required.

KEY WORDS:

Physical therapy, PT, Occupational therapy, OT, 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, habilitation, habilitative, rehabilitation, rehabilitative, WHCRA, Women's Health and Cancer Rights Act

APPROVED BY GOVERNING BODIES:

Not applicable

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits. Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply.  Refer to member’s benefit plan.

In general, most 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.

* NOTE:  Please refer to the member’s Summary Plan Description for any Autism, or Autism Spectrum Disorder (ASD), and/or Applied Behavioral Analysis (ABA) Benefits. There are varying benefit plans for these services. Please verify benefits prior to applying policy criteria, as benefits will supersede this policy.

CURRENT CODING:

CPT codes:

Physical Medicine and Rehabilitation

HCPCS codes:

Allied Health Services

Other

Modifier:

To report habilitation services, append the following modifier:

96              Habilitative services 

To report rehabilitation services, append the following modifier:

97              Rehabilitative services 

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):663-667.
2. American Physical Therapy Association. Access to, admission to, and patient/client rights within physical therapy services. Available at: https://www.apta.org/apta-and-you/leadership-and-governance/policies/access-admission-patient-client-rights.
3. American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd Edition revised. American Physical Therapy Association. January 2003.
4. American Physical Therapy Association. Physical Therapy for Older Adults. Available at: https://www.apta.org/apta-and-you/leadership-and-governance/policies/pt-for-older-adults.
5. American Physical Therapy Association. Provision of Physical Therapy Interventions and Related Tasks. Available at:www.apta.org.
6. American Physical Therapy Association. Standards of Practice for Physical Therapy. Available at: https://www.apta.org/apta-and-you/leadership-and-governance/policies/standards-of-practice-pt.
7. Foruzandeh N, Parvin N. Occupational therapy for inpatients with chronic schizophrenia: a pilot randomized controlled trial. Jpn J Nurs Sci. 2013 Jun; 10(1): 136-41.
8. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
9. 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): 107-15.
10. 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):CD003585.
11. 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):2402-2448.
12. Moyers PA. The guide to occupational therapy practice. American Occupational Therapy Association. Am J Occup Ther. 1999; 53(3):247-322.
13. NIH Consensus Statement. Rehabilitation of persons with traumatic brain injury. 1998 Oct 26-28; 16(1):1-41. Available at: www.nichd.nih.gov/publications/pubs/TBI_1999/Pages/NIH_Consensus_Statement.aspx.
14. Reitz SM, Austin DJ, Brandt LC, et al. Guidelines to the Occupational Therapy Code of Ethics. Am J Occup Ther. 2006; 60(6):652-668.
15. 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):1283-1290.
16. 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):247-254.
17. Steultjens EM, Dekker JJ, Bouter LM, et al. Occupational therapy for rheumatoid arthritis. Cochrane Database of Syst Rev. 2004; (1):CD003114.
18. Sturkenboom IH, Graff MJ, et al. Efficacy of occupational therapy for patients with Parkinson’s disease: a randomised controlled trial. Lancet Neruol. 2014 Jun; 13(6):557-66.

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

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.

Medical Policy Group, November 2016 (3): 2016 Update to Title, Description, Key Points, Key Words, Coding and References; Policy Statements updated to reflect clarifying current services as “rehabilitative” and adding “habilitative” services effective 01/01/17.  All aspects of osteopathic & chiropractic treatments moved from this policy to newly created medical policy #629; 2017 Coding update information added as well

Medical Policy Administration Committee, November 2016

Available for comment November 10 through December 26, 2016

Medical Policy Group, December 2017 (3):  2017 Updates to Coding & Previous Coding sections due to 2018 Coding update; clarified benefit note regarding autism, ASD, ABA; no change in policy statement; other 2018 Coding update information added as well (note – new, revised and deleted codes fell within ranges so no edits needed)

Medical Policy Group, May 2018 (5):  Updated coding section to add S8990; no change in policy statement.

Medical Policy Group, January 2019 (4): Effective 1/1/19, removed pelvic floor dysfunction therapeutic exercise as investigational. Clarified exercise equipment includes FES cycle ergometer. Key words added: FES, functional electrical stimulation, cycle ergometer.

Medical Policy Administrative Committee: January 2019

Available for Comment: January 9 – February 23, 2019

Medical Policy Group, June 2019 (6): Functional Electrical Stimulation (FES) cycle ergometer devices transferred to MP#358 Functional Neuromuscular Electrical Stimulation.

Medical Policy Group, September 2020: Quarterly coding update.  Added new HCPCS code T2047 to Current Coding.

Medical Policy Group, August 2021 (4):  Updates to References. Removed policy statements effective for dates of service prior to January 1, 2017. Removed Previous Coding section (codes deleted in 2016 and 2017).

Medical Policy Group, August 2022 (4): Updates to References. Removed policy statements effective for dates of service 1/1/17 – 12/31/18.  No change to policy intent.

Medical Policy Group, November 2022 (6): Updates to Policy statement to include coverage may be subject to legislative mandates: Federal Women's Health and Cancer Rights Act (WHCRA).

Medical Policy Group, December 2022 (6): Added Key Words: WHCRA, Women's Health and Cancer Rights Act

Medical Policy Group, August 2023 (4): Reviewed by consensus.  No new published peer-reviewed literature available that would alter the coverage statement in this policy. No change to policy statements.

Medical Policy Group, August 2024 (4): REviewed by consensus.  No new published peer-reviewed literature available that would alter the coverage statement in this policy. No change to policy statements.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-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.

The plan 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. The plan 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.

As a general rule, benefits are payable under 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.