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Date Printed: August 21, 2017: 07:43 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Subject: Physical Therapy (PT) and Occupational Therapy (OT)

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► Coverage

 

This medical coverage guideline is not an authorization, certification, explanation of benefits, or a guarantee of payment, nor does it substitute for or constitute medical advice. All medical decisions are solely the responsibility of the patient and physician. Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. This medical coverage guideline applies to all lines of business unless otherwise noted in the program exceptions section.

 

DESCRIPTION

Physical Therapy

Physical therapy, or PT, is a plan of care using special exercises and other methods to improve:

• posture

• movement

• strength

• stamina

• balance

• coordination

• joint movement

• flexibility

• performing life activities

• pain

Each plan of care is designed to restore or improve function of the body. Care plans include the use of exercise, heat, cold, electric current and/or massage.

Occupational Therapy

Occupational therapy, or OT, is a plan of care using precise activities to meet goals set for you. These activities are meant to restore or improve skills used in the activities of daily living (ADLs). Dressing, eating and personal hygiene are examples of activities of daily living. The aim of occupational therapy is to restore or improve the function of the shoulder, elbow, wrist, or hand.

The methods used in therapy may be passive or active. Passive methods are motions applied to the body by another person or a device. Passive methods are often used when the aim is to reduce pain and swelling. When pain and swelling begins to ease, active methods are used. Active methods are actions performed by the patient working to control their movements. The aim, at that point, is to restore joint movement and flexibility.

Visit the Clinical View of this guideline for more information.

Visit WebMD for more information on physical therapy and occupational therapy.

COVERAGE

 

Note: For all medical decisions about this service, Florida Blue uses the Position Statement in the Clinical View of this medical coverage guideline. To make the best decision for your health needs, talk to your doctor. The services covered vary from health plan to health plan. Refer to your health plan contract for complete information about your coverage.

 

Physical or occupational therapy may be covered if certain requirements are met including:

• Physical or occupational therapy is ordered by your doctor.

• Treatment is given according to a written plan.

• The treatment plan has clear and achievable short and long term goals that are measureable.

• The treatment plan lists the type, length, and frequency of therapy.

• The treatment plan is based on the patient’s likely course and outcome of care.

• Services are needed and will likely restore or improve physical function.

• Only a trained licensed specialist may provide care as a part of a treatment plan.

• Your doctor must review and approve your treatment plan every 60 days for care to continue.

Massage therapy provided by a licensed massage therapist may be covered when the following requirements are met:

• Your doctor submits a written statement saying massage therapy is medically necessary.

• Your doctor submits the number of massage treatments to be given.

NOTE: Massage therapy services are subject to the limitations applied to all other physical therapy services.

Comprehensive motion analysis, or walk analysis, is testing performed before or after surgery to assess muscle performance. This testing is covered only for patients with cerebral palsy.

The following physical therapy services are not covered:

• Non skilled services: care which does not require the skills of a trained professional.

• Duplicate care: a patient may receive both physical and occupational therapy. However, the treatment plans must be different and separate. The same treatment may not be given by different providers.

• Maintenance programs: treatment which preserves current function and prevents decline of function. When the goals of the treatment plan have been met, maintenance begins. Maintenance may also begin when no further progress is evident or expected.

The following services are considered experimental or investigation because their effects have not been proven by scientific research:

• Electrodynography

• Skeletal analysis systems

• Dry hydrotherapy

• Augmented Soft-tissue Mobilization (ASTM)

• Kinesio taping

• Dynamic Method of Kinetic Stimulation (MEDEK therapy or Cuevas Medek Exercises CME)

• Interactive metronome program

Visit the Clinical View of this guideline for specific coverage information.

PROGRAM EXCEPTIONS

• Federal Employee Program (FEP): Certain exceptions apply.

• State Account Organization (SAO): Certain exceptions apply.

• Medicare Advantage products: Certain exceptions apply.

Visit the Clinical View of this guideline for more coverage information.

Refer to your health plan contract for complete information about your coverage.

Date Printed: August 21, 2017: 07:43 PM