| Utilization Management Section - Physical Therapy
| Topic: Physical Therapy |
Date of Origin: 01/1996 |
| Section: UM |
Policy No: 6 |
| Approved Date: 12/08/2009 |
Effective Date: 01/01/2010 |
| Next Review Date: 10/2011 |
|
IMPORTANT REMINDER
Regence Medical Policies are developed to provide guidance for members and providers regarding
coverage in accordance with contract terms. Benefit determinations are based in all cases on
the applicable contract language. To the extent there may be any conflict between the Medical
Policy and contract language, the contract language takes precedence.
PLEASE NOTE: Contracts exclude from coverage, among other things, services or procedures that
are considered investigational or cosmetic. Providers may bill members for services or
procedures that are considered investigational or cosmetic. Providers are encouraged to inform
members before rendering such services that the members are likely to be financially responsible
for the cost of these services.
Description
Physical therapy is the treatment of a 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,
activities of daily living and alleviating pain.
Treatment may include active and passive modalities
using techniques based upon biomedical and neurophysiological
principles (e.g., hydrotherapy, electrotherapy, application
of heat and cold).
Hippotherapy, also referred to as equine movement
therapy, consists of riding horse back in various positions.
Hippotherapy has been proposed as a type of physical
therapy for patients, usually children, with lower
extremity spasticity secondary to neuromuscular disorders
(e.g., cerebral palsy, spinal cord injury). The
movement of the horse is believed to be effective in
muscle and neurological re-education, resulting in
a decrease in spasticity and balance problems.
Policy/Criteria
| I. |
Physical therapy may be medically
necessary when all of the following criteria
are met: |
| |
A. |
Services are for the treatment of
a covered injury, illness or disease and are appropriate
treatment for the condition |
| |
B. |
Treatments are expected to result
in significant, functional improvement in a reasonable,
and generally predictable period of time, or are
necessary for the establishment of a safe and effective
maintenance program. Treatments should be directed
towards restoration or compensation for lost function.
The improvement potential must be significant in
relation to the extent and duration of therapy
required |
| |
C. |
Therapy is prescribed by an eligible
provider |
| |
D. |
Therapy is rendered by an eligible
provider |
| |
E. |
The services must be currently accepted
standards of medical practice and be specific and
effective treatments for the patient’s existing
condition |
| |
F. |
The complexity of the therapy and
the patient’s condition must require the
judgment and knowledge of a physician or a licensed
physical therapist |
| |
G. |
Services do not duplicate those provided
concurrently by any other therapy, particularly
occupational therapy |
| |
H. |
Services are not for the treatment
of psychological conditions |
| |
|
|
|
| II. |
If the above criteria are met, the
following guidelines apply: |
| |
|
| |
The treatments
listed below require the skills and expertise of
a licensed eligible provider. Different modalities,
including but not limited to ultrasound, therapeutic
exercise and manual therapy, may be employed in
the delivery of these treatments and procedures.
In conjunction with delivering these services,
the provider is expected to provide teaching and
training to the patient and/or caregivers. Maintenance
programs must be taught before the end of the active
rehabilitation program. |
| |
|
|
|
| |
A. |
Assessment |
| |
|
1. |
Assessment of the patient's functional ability
by applying muscle, joint, nerve and functional
ability tests |
| |
|
2. |
Assessment of the patient's home safety and equipment
need |
| |
B. |
Teaching |
| |
|
1. |
Pain relief measures |
| |
|
2. |
Development or restoration of function using
physical means (e.g., active and passive exercises,
muscle re-education, functional training, transfer
activities) |
| |
|
3. |
Maintenance of maximum performance (maintenance
program) |
| |
|
4. |
Use and care of wheelchairs, braces, canes, crutches,
prosthetic and orthotic devices |
| |
|
|
|
| |
C. |
Re-evaluation
if there is a change in condition requiring an
adjustment in a maintenance program |
| |
D. |
Gait analysis
and training, as described in TRG Medical Policy,
Medicine No. 107, for a clearly defined gait disorder |
| |
E. |
Stress
incontinence evaluation and training. Physical
therapy is a conservative approach for treating
pelvic floor muscle weakness causing stress incontinence. |
| |
F. |
Temporomandibular
Joint Dysfunction (TMD) Treatment. Physical therapy,
including diathermy, infrared, heat and cold treatment
and manipulation may be considered medically necessary
in the treatment of TMD. |
| |
|
|
|
| III. |
The following
services are not considered medically necessary: |
| |
|
|
|
| |
A. |
Training
in non-essential self-help or recreational tasks
(e.g., homemaking, gardening, vocational and educational
activities, driving) |
| |
B. |
Maintenance
therapy |
| |
|
Maintenance
therapy is defined as ongoing therapy after the
patient has reached maximum rehabilitation potential,
or functional level has shown no significant improvement
for two weeks, and initial instruction in a maintenance
program is completed. This is particularly applicable
to patients with chronic, stable conditions where
skilled supervision/interventions is no longer
required and further clinical improvement cannot
reasonably be expected from continuous ongoing
care. This includes but is not limited to: |
| |
|
1) |
Therapy that is supportive
rather than corrective in nature |
| |
|
2) |
Therapy that is intended
to maintain a gradual process of healing or to
prevent deterioration or relapse |
| |
|
3) |
Ongoing treatment solely
to improve endurance, strength or distance |
| |
|
4) |
Passive exercises to
maintain range of motion that can be carried out
by nonskilled persons |
| |
|
5) |
A general exercise
program to promote overall fitness |
| |
|
6) |
Treatment that is intended
to provide diversion or general motivation |
| |
|
7) |
Treatment that seeks
to prevent disease, promote health, and prolong
and enhance quality of life. |
| |
C. |
Massage
therapy when provided as a stand-alone procedure
rather than as part of a comprehensive therapeutic
treatment plan |
| |
D. |
Instruction
of other agency or professional personnel in the
patient’s physical therapy program |
| |
E. |
Collaboration
with other agency or professional personnel or
with other community resources |
| |
F. |
Emotional
support, adjustment to extended hospitalization
and/or disability, and behavioral readjustment |
| |
|
|
|
| IV. |
Hippotherapy
is considered investigational. |
Scientific Background
Hippotherapy
The majority of the literature regarding hippotherapy
consists of small case series. (3,4) MacKinnon and
colleagues published a small randomized study of 19
patients that reported no significant effects in the
majority of outcome measures. (5) Sterba and colleagues
reported on the outcomes of horseback riding in 17
subjects with cerebral palsy. (6) Gross motor function
measurements were assessed before and after a once
weekly horseback riding program for 18 weeks. Gross
motor function total scores improved by 7.6% after
18 weeks, returning to baseline six weeks after the
program ended. This small trial is inadequate to permit
scientific conclusions. Benda and colleagues used surface
electromyography to assess outcomes in 15 children
with cerebral palsy who were randomized to either horseback
riding or to sitting stationary astride a barrel. (7)
The authors reported that the hippotherapy group showed
greater symmetry of muscle activity. The clinical significance
of this outcome is uncertain. An updated search
of the MEDLINE database through February 27, 2007 failed
to identify any articles that alter the conclusions
reached above.
References
- BlueCross BlueShield Association Medical Policy
Reference Manual, Policy No. 8.03.02
- BlueCross BlueShield Association Medical Policy
Reference Manual, Policy No. 8.03.12
- McGibbon NH, Andrade CK, Widener G et al. Effect
of an equine-movement therapy program on gain,
energy expenditure, and motor function in children
with spastic cerebral palsy: a pilot study. Dev
Med Child Neurol 1998;40(11):754-62
- Bertoti DB.
Effect of therapeutic horseback riding on posture
in children with cerebral palsy. Phys Ther 1998;68(10):1505
- MacKinnon JR, Noh S, Lariviere J et al.
A study of therapeutic effects of horseback riding
for children with cerebral palsy. Phys
Occup Ther Pediatr 1995;15(1):17
- Sterba JA, Rogers BT, France
AP et al. Horseback riding in children with cerebral
palsy: effect on gross motor function. Dev
Med Child Neurol 2002;44(5):301
- Benda W, McGibbon NH, Grant KL. Improvements in
muscle symmetry in children with cerebral palsy after
equine-assisted therapy (hippotherapy). J
Altern Complement Med 2003;9:817-25
Cross References
Occupational
Therapy, Regence Medical Policy Manual, Utilization
Management, Policy No. 4
Gait
Analysis, Regence Medical Policy Manual, Medicine,
Policy No. 107
Vertebral
Axial Decompression, Regence Medical Policy
Manual, Medicine, Policy No. 45
| Codes |
Number |
Description |
|
CPT |
97001 |
Physical therapy evaluation |
|
|
97002 |
Physical therapy re-evaluation |
| |
97010-97028 |
Physical medicine and rehabilitation modalities,
supervised, code range |
| |
97032-97039 |
Physical medicine and rehabilitation modalities,
constant attendance, code range |
| |
97110-97530 |
Therapeutic procedures, code range |
| |
97542 |
Wheelchair management (e.g., assessment, fitting,
training), each 15 minutes |
| HCPCS |
S8940 |
Equestrian/Hippotherapy; per session |
| |
S9131 |
Physical therapy; in the home, per diem |
Utilization Management Table of Contents 
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