BlueCross and BlueShield of Montana Medical Policy/Codes
Non Covered Physical Therapy Services
Chapter: Therapies
Current Effective Date: March 15, 2014
Original Effective Date: October 25, 2013
Publish Date: January 14, 2014
Revised Dates: January 14, 2014
Description

Physical therapy services include therapeutic interventions tailored to the specific needs of the patient. Such interventions include therapeutic exercise programs to increase strength and endurance, as well as application of various other modalities including, but not limited to, heat, cold, electrical stimulation, ultrasound, hydrotherapy, and massage or mobilization techniques. These services must be rendered under a written plan of care established by a physician or other qualified non-physician practitioner (e.g., physician assistant), and must be performed by a licensed physical therapist, or by assistive personnel under the supervision of a licensed physical therapist; if performed by assistive personnel, such services shall not exceed his or her education, training and/or licensure. To be considered medically necessary, these modalities must also be proven and accepted as effective and/or safe for the treatment of disease or injury.

Various types of treatment that do not generally require the skills of a licensed physical therapist include, but are not limited to:

  • Passive range of motion (ROM) treatment, which is not related to restoration of a specific loss of function;
  • Any of the following treatments when given alone or to a patient who presents no complications of disease, illness, or injury: hot packs, hydrocollator, infrared heat, whirlpool baths, paraffin baths, Hubbard tank, contrast baths.

A maintenance program consists of activities that preserve the patient’s present level of function and prevent regression of that function. Maintenance begins when:

  • therapeutic goals of the treatment plan have been achieved, and/or when no additional functional progress is apparent or expected to occur; and/or
  • maximum medical improvement has been achieved; and/or
  • therapy fails to provide durable, condition-specific corrective benefit; and/or
  • therapy is not reasonably expected to improve health status in a reasonable and predictable period of time; and/or
  • therapy is not primarily to support continuance of the improvement achieved; and/or
  • therapy is not primarily provided to prevent relapse.

Maintenance services typically do not require the services of a licensed physical therapist and include, but are not limited to:

  • Repetitive exercise to improve gait, maintain strength and endurance, and assistive walking such as that provided in support for feeble or unstable patients;
  • Range of motion and passive exercises that are not related to the restoration of a specific loss of function, but are useful in maintaining range of motion in paralyzed extremities;
  • General exercise programs, even when recommended by a physical therapist.

Kinesiology does not diagnose or treat disease, but rather uses manual muscle testing (analysis which detects minor functional imbalances) to detect the root causes of illness and to assess ways to improve your health and well-being. Kinesiology uses massage, nutrition, and contact points to help with emotions and anxieties, specific personal dietary intake and supplements for nutritional deficiencies, structural imbalances, and energy blocks. Kinesiology is primarily preventive in that it is intended to balance the whole person, to enhance health and well-being, and to ward off disease.

Percussion hammer is a device that gives deep muscle massage with vibration and percussion of as much as 3000 pulses per minute.

Spray and Stretch Technique involves passively stretching the target muscle while simultaneously applying Fluori-Methane or “vapor coolant” spray topically. Spray and Stretch is thought to produce temporary anesthesia by lowering skin temperature, thereby allowing the muscle to be passively stretched toward normal length; this is done to help activate trigger points, relieve muscle spasm, and reduce referred pain.

Fluidotherapy is a form of dry, convective heating that uses pulverized organic materials that are suspended and circulated in a heated air stream.

Intermittent motorized traction and intersegmental traction are methods of mechanical massage and spinal mobilization of soft tissue. This is done using a specialized bench table that has roller-type cams beneath the surface. The rollers slowly travel the length of the spine, stretching spinal joints.

Craniosacral therapy (CST) is a type of gentle manipulation and light-touch therapy involving the bones and soft tissues of the head, spine, and pelvis. Practitioners assert CST reestablishes the normal flow of fluids, particularly cerebrospinal fluid, and thus restores health; no significant clinical trials have tested these assertions. CST has been used to treat a variety of disorders, including pain, injuries, and fatigue, as well as to reduce tension and increase general well-being and health.

Diathermy is a form of heat therapy in which high-frequency electrical currents are used to heat deep muscular tissues. Heat accelerates tissue repair by increasing local blood flow and speeding up cellular metabolism, relieves stiffness by helping tissues to relax and stretch, and increases the patient’s pain threshold by reducing nerve fiber sensitivity. There are several types of diathermy. In shortwave diathermy, the body part to be treated is placed between two capacitor plates and heat is generated as high-frequency electrical current travels through the body tissue between the plates. Ultrasound diathermy uses high-frequency acoustic vibrations to generate heat in deep tissue. Microwave diathermy uses radar waves to heat tissue, but these cannot penetrate deep tissue. Other types of diathermy can be used to kill abnormal growths, such as warts and tumors, and to help control bleeding in surgical procedures.

There are two types of lasers: high power and low power. High power lasers give off heat and are used to cut through tissue. Low power lasers, or LLLT, do not give off heat. LLLT produces beams of red light that can penetrate the surface of the skin and provide topical heating through photochemical processes in the cells. LLLT is used for a variety of purposes. When used for cessation of smoking, LLLT works along the same principle as acupuncture, and is sometimes called laser acupuncture. This consists of a low-level laser beam to specific points of the body, which is said to control withdrawal symptoms by stimulating release of endorphins.

Neurostructural integration therapy is a non-invasive type of soft tissue bodywork therapy that is used for a wide range of conditions from acute pain to chronic conditions. In theory, neurostructural integration therapy causes deep relaxation, allowing the musculature of the body to ‘reorganize’ itself via natural activation of various neural reflexes, which is thought to provide lasting relief from pain and dysfunction while increasing energy levels.

A hydrocollator is a heating unit that provides a supply of temperature-consistent hot packs.

A hydrotherapy bed is a type of water bed that has strategically located spa jets. The jets create water pulsation that heats and massages the patient’s back when he is lying on the bed. This has been used as a substitute for hot packs and massage. 

Gyrotonic machines are thought to increase range of motion and develop coordination by working major muscle groups interdependently and in an integrated manner. The Gyrotonic Pulley Tower Combination Unit was the first piece of Gyrotonic Equipment to be sold to the public. Since then other equipment has been developed, including: the Jumping Stretching Board, the Archway, the Leg Extension Unit, and the GYROTONER®. Each piece of equipment has it's own unique features, and functions, providing an extensive range of exercise options. These pieces of equipment are not part of a physical therapy program. (24)

Kinesio Tape (KT) is a specialized, thin, elastic tape that can be stretched up to 120%~140% of its original length, making it quite elastic compared with conventional taping. Kinesio taping differs from conventional taping and/or strapping in that instead of providing support, the purpose of kinesio taping is to assist with partial to full range of motion by applying pulling forces to the skin over the targeted muscles. (25) KT is air permeable and water resistant and can remain in place over several days.

The Pettibon System is described as follows. “In The Pettibon System, exercises are performed to decrease hysteresis in these tissues using the Wobble Chair™ and the Pettibon Repetitive Cervical Traction™. From a clinical standpoint, the exercises are performed at the beginning of a patient visit prior to manipulative intervention. This reduces the overall resistance of the soft tissues to the manipulative force, thus allowing that force to assume a more corrective role. Once the manipulative techniques are administered, the patient then wears the Pettibon Weighting System while the soft tissue is less resistant. Therefore, in The Pettibon System, all of the components of the spine are corrected and rehabilitated as a unit, using rehabilitative procedures designed to target each type of tissue specifically. Finally, another type of isometric exercise is used to rehabilitate normal spine alignment. Pettibon has slightly modified the performance of these exercises by creating the Linked Exercise Trainer™ on which they are performed...Areas of muscle imbalance can therefore be isolated and strengthened using the Linked Exercise Trainer, thus reinforcing corrective spinal changes.” (26) One of the uses of the Pettibon System is to correct scoliosis.

Policy

Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.  Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.

Coverage

Certain physical therapy modalities are considered not medically necessary as they have not been proven to be effective and/or safe for the treatment of disease or injury, or are provided primarily for the convenience of the member, the caregiver or the provider. These include but are not limited to:

  • Physical therapy services that do not require the skills of a qualified provider of physical therapy services, as well as services that are considered to be a maintenance program;
  • Kinesiology;
  • Percussion hammer;
  • Spray and Stretch technique for myofascial pain, including but not limited to Fluori-Methane and vapor coolant;
  • Fluidotherapy (examples include but are not limited to Fluido DHT®, FLU110D®);
  • Intermittent motorized traction and intersegmental traction, methods of mechanical massage and spinal mobilization of soft tissue (examples include but are not limited to Anatomotor™);
  • Craniosacral therapy;
  • Special exercise equipment, including but not limited to gyrotonic machines, and including rental and/or purchase of such equipment (check member’s contract carefully for possible exclusion).

Rental and/or purchase of hydrocollators is considered not medically necessary as they are considered a convenience item when used at home. (NOTE: Application of heat packs in the Physical Therapy setting may be considered medically necessary when criteria for Physical Therapy are met.

Hydrotherapy bed treatment is considered not medically necessary.

Duplicate therapy is considered not medically necessary. When patients receive both physical and occupational therapy, the therapies should provide different treatments and not duplicate the same treatment. They must also have separate treatment plans and goals.

All of the following physical therapy modalities are considered experimental, investigational and/or unproven:

  • Diathermy, ultrasound and heat treatments for pulmonary conditions;
  • Electromagnetic therapy (e.g., Diapulse®);
  • Home use of diathermy devices (e.g., Magnatherm®), including, but not limited to:
    • Radiofrequency diathermy;
    • High frequency diathermy;
    • Short wave diathermy;
    • Ultrasound diathermy;
    • Microwave diathermy;
  • Low level laser therapy (LLLT) for any use, including but not limited to treatment for carpal tunnel syndrome and/or treatment for cessation of smoking.  LLLT is also known by many other names including, but not limited to therapeutic laser, low-power laser, low-energy laser, biostimulating laser, photobiostimulating laser, laser phototherapy, cold laser (examples include, but are not limited to: Helium Neon Laser®, HairMax Laser Comb®, THOR DD2 Laser System®, MicroLight 830®;
  • Neurostructural integration technique;
  • Kinesio taping;
  • The Pettibon System, including but not limited to the Wobble Chair and the Pettibon Repetitive Cervical Traction.

Policy Guidelines

Caution:  Non-covered physical therapy procedures are frequently billed using traditional physical therapy modality codes that are covered. Example: Intersegmental traction is inappropriately billed using 97012 (mechanical traction).

Rationale

An updated MedLine search was conducted through July 2007 on kinesiology, percussion hammer, spray and stretch technique, fluidotherapy, intermittent motorized traction and intersegmental traction, and craniosacral therapy. Based on this Medline search, these modalities are not known to be safe and/or effective in improving health outcomes as determined by credible scientific evidence published in the peer-reviewed medical literature, and as such are not considered medically necessary. 

The application of deep heat using diathermy devices has inherent risks that make these devices inappropriate for unsupervised use at home. Diathermy devices are institutional equipment that must always be used by or under the supervision of a qualified provider of physical therapy services. An updated MedLine search conducted through May 2008 on diathermy, ultrasound and heat treatments for pulmonary conditions, electromagnetic therapy and/or pulsed short wave therapy, low level laser therapy, and neurostructural integration therapy failed to provide significant scientific evidence or peer-reviewed medical literature that:

  • Permits conclusions on the effect of these therapies;
  • Demonstrates an improvement in net health outcome through use of these therapies;
  • Demonstrates that any of these therapies are as beneficial as established alternatives.

2013 Update

A search of peer reviewed literature through October 2013 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy. In addition, no clinical trials were found that would support the use of gyrotonic machines in the physical therapy setting, or to support the use of the Pettibon System, including the Wobble Chair and/or the Pettibon Repetitive Cervical Traction.

In 2008, Thelen et al. conducted a prospective, randomized, double-blinded, clinical trial using a repeated-measures design to determine the short-term clinical efficacy of KT when applied to college students with shoulder pain, as compared to a sham tape application. Forty-two subjects clinically diagnosed with rotator cuff tendonitis/impingement were randomly assigned to 1 of 2 groups: therapeutic KT group or sham KT group. Subjects wore the tape for 2 consecutive 3-day intervals. Self-reported pain and disability and pain-free active ranges of motion (ROM) were measured at multiple intervals to assess for differences between groups. The therapeutic KT group showed immediate improvement in pain-free shoulder abduction (mean +/- SD increase, 16.9 degrees +/- 23.2 degrees; P = .005) after tape application. No other differences between groups regarding ROM, pain, or disability scores at any time interval were found. The authors concluded that KT may be of some assistance to clinicians in improving pain-free active ROM immediately after tape application for patients with shoulder pain. Utilization of KT for decreasing pain intensity or disability for young patients with suspected shoulder tendonitis/impingement is not supported. (27)

In 2009, González-Iglesias et al. reported a randomized clinical trial to determine the short-term effects of kinesio taping, applied to the cervical spine, on neck pain and cervical range of motion in individuals with acute whiplash-associated disorders (WADs). Forty-one patients (21 females) were randomly assigned to 1 of 2 groups: the experimental group received kinesio taping to the cervical spine (applied with tension) and the placebo group received a sham kinesio taping application (applied without tension). Both neck pain (11-point numerical pain rating scale) and cervical range-of-motion data were collected at baseline, immediately after the KT application, and at a 24-hour follow-up by an assessor blinded to the treatment allocation of the patients. Mixed-model analyses of variance (ANOVAs) were used to examine the effects of the treatment on each outcome variable, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction. The group-by-time interaction for the 2-by-3 mixed-model ANOVA was statistically significant for pain as the dependent variable (F = 64.8; P<.001), indicating that patients receiving kinesio taping experienced a greater decrease in pain immediately post-application and at the 24-hour follow-up (both, P<.001). The group-by-time interaction was also significant for all directions of cervical range of motion: flexion (F = 50.8; P<.001), extension (F = 50.7; P<.001), right (F = 39.5; P<.001) and left (F = 3.8, P<.05) lateral flexion, and right (F = 33.9, P<.001) and left (F = 39.5, P<.001) rotation. Patients in the experimental group obtained a greater improvement in range of motion than thosein the control group (all, P<.001). The authors concluded that patients with acute WAD receiving an application of kinesio taping, applied with proper tension, exhibited statistically significant improvements immediately following application of the KT and at a 24-hour follow-up. However, the improvements in pain and cervical range of motion were small and may not be clinically meaningful. Future studies should investigate if kinesio taping provides enhanced outcomes when added to physical therapy interventions with proven efficacy or when applied over a longer period. (28)

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

Refer to the ICD-9-CM manual.

ICD-10 Codes

Refer to the ICD-10-CM manual.

Procedural Codes: 97012, 97024, 97026, 97034, 97035, 97039, 97139, 97799, E0225, E0239, G0295, G0329, S8948
References
  1. Special Medicare Part B Newsletter #136, 6/15/95, Helium Neon Laser Bio stimulation
  2. Journal of Manipulative and Physiological Therapeutics, Vol. 18 #8 (Oct. '95), #6 (July, Aug. '95), #2 (Feb. 95).
  3. De Bie, R.A., de Vet, H.C., et al. Low level laser therapy in ankle sprains: a randomized clinical trial. Archives of Physical Medicine and Rehabilitation (1998 November) 79(11):1415-20.
  4. Marks, R., and de Palma, F. Clinical efficacy of low power laser therapy in osteoarthritis. Physiotherapy Research International (1999) 4(2):141-57.
  5. Yiming, C., Changix, Z., et.al. Laser Acupuncture for Adolescent Smokers—a Randomized Double-Blind Controlled Trial. American Journal Chinese Medicine. (2000) 28-(3-4):443-9.
  6. Frick, Lisa. Diathermy. Gale Encyclopedia of Alternative Medicine (2001) http://www.findarticles.com (Accessed on 2005 January 11).
  7. Alvarez, D., and P. Rockwell. Trigger points: Diagnosis and Management. American Academy of Family Physicians (2002 February 15) http://www.aafp.org (Accessed on 2004 December 28).
  8. Physical Therapy-Archived. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2002 April) Therapy 8.03.02.
  9. White, A.R., Rampes, H., et.al. Acupuncture for smoking Cessation. Cochrane Database Systematic Review (2002) (2):CD000009.
  10. Garrison, N.M., Christakis, D.A., et.al. Smoking Cessation Interventions for Adolescents: A Systematic Review. American Journal Preventive Medicine (2003 November) 25(4):363-7. 
  11. Sievert, Thomas. Intersegmental Traction. Sievert Clinic of Chiropractic. http://www.sievertclinic.com (Accessed on 2004 December 23).
  12. Low Level Laser Therapy for Painful Joints. Available at http://www.jr2.ox.ac.uk (Accessed on 2004 November 8).
  13. Brousseau, L., Welch, V., et al. Low level laser therapy for osteoarthritis and rheumatoid arthritis: a metaanalysis. http://www.jrheum.com (Accessed on 2004 November 8).
  14. What is craniosacral therapy? http://www.garynull.com (Accessed on 2005 January 12).
  15. Craniosacral Therapy. http://www.wholehealthmd.com (Accessed on 2005 January 12).
  16. What is Systemic Kinesiology. www.kinesiology.co.uk/info.htm Accessed 1/6/2005.  
  17. Behavioral training and oven mitts become a recipe for recovery.  Psychology Matters. American Psychological Association Online. 2005. http://www.psychologymatters.org .
  18. CI Therapy overview. UAB Health System (2004). http://www.taubtherapy.com .
  19. Stop smoking today! Advanced Laser Solutions. http://www.seniorsapprove.com (Accessed on 2005 April 18). 
  20. Quit smoking laser therapy treatment. Freedom Laser Therapy, Inc. http://www.freedomlasertherapy.com (Accessed on 2005 April 18). 
  21. Neurostructural Integration Technique. The Bowen Therapists Federation of Australia. http://www.bowen.asn.au (Accessed on 2007 August 2).
  22. Neurostructural integration technique (advanced Bowen therapy) Positive Health Publications, Ltd. (1994-2002).  http://www.positivehealth.com (Accessed on 2007 August 2).
  23. Neurostructural integration technique. The Freedom Center (2007). http://www.thefreedomcenter.com (Accessed on 2007 August 2).
  24. Gyrotonic® Equipment. The Official Website of the Gyrotonic Expansion System. Gyrotonic Sales Corp. 2013. Available at www.gyrotonic.com (Accessed November 13, 2013).
  25. Wen-Chi C, Wei-Hsien H, et al. Effects of kinesio taping on the timing and ratio of vastus medialis obliquus and vastus lateralis muscle for person with patellofemoral pain. Journal of Biomechanics 40(S2):S318. Presentation 216, XXI ISB Congress, Podium Sessions, July 3 2007. Available at  http://www.kinesiologytapeproducts.com (Accessed Nov 13, 2013).
  26. Morningstar M, Pettibon BR, Remz CL. The Pettibon System: A Neurologic Approach to Spine and Posture Correction. Available at  http://www.scoliosisrehabilitationcenter.com (Accessed November 13, 2013).
  27. Thelen MD, Dauber JA, and Stoneman PD. The clinical efficacy of kinesio tape for shoulder pain: a randomized, double-blinded, clinical trial. J Orthop Sports Phys Ther. 2008 Jul; 38(7):389-95.
  28. González-Iglesias J, Fernández-de-Las-Peñas C, et al. Short-term effects of cervical kinesio taping on pain and cervical range of motion in patients with acute whiplash injury: a randomized clinical trial. J Orthop Sports Phys Ther. 2009 Jul; 39(7):515-21.
History
June 2013  New 2013 BCBSMT medical policy.
March 2014 Document updated with literature review. Coverage changed as follows:  1) The following was added as not medically necessary:  Special exercise equipment, including but not limited to gyrotonic machines, and including rental and/or purchase of such equipment (check member’s contract carefully for possible exclusion). 2) The not medically necessary statement regarding hydrocollators was revised to clarify “rental and/or purchase” and the following was added: (NOTE: Application of heat packs in the Physical Therapy setting may be considered medically necessary when criteria for Physical Therapy are met (as outlined in medical policy THE803.010). 3) The following was added to the list of experimental, investigational and/or unproven: a) Kinesio Taping; b) The Pettibon System, including but not limited to the Wobble Chair and the Pettibon Repetitive Cervical Traction.
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Non Covered Physical Therapy Services