2.0 DESCRIPTION
2.1 The treatment
by physical means, hydrotherapy, heat, or similar modalities, physical
agents, bio-mechanical and neuro-physiological principles, and devices
to relieve pain, restore maximum function, and prevent disability
following disease, injury or loss of a body part.
2.2 Physical
therapy services consist of the physical evaluation of a patient
by muscle testing and other means and the prescribed therapeutic
treatment and services of a definite functional nature.
2.3 Physical
therapy to improve, restore, or maintain function, or to minimize
or prevent deterioration of function of a patient when prescribed
by a physician is covered in accordance with the rehabilitative
therapy provisions found in
Section 18.1.
3.0 POLICY
3.1 Benefits
are payable for inpatient or outpatient physical therapy services
that are determined to be medically necessary for the treatment
of a covered condition, and that are directly and specifically related
to an active written regimen.
3.2 Physical therapy services
must be prescribed by a physician, certified Physician Assistant
(PA working under the supervision of a physician), or certified
Nurse Practitioner (NP) and professionally administered to aid in
the recovery from disease or injury to help the patient in attaining
greater self-sufficiency, mobility, and productivity through exercises
and other modalities intended to improve muscle strength, joint
motion, coordination, and endurance.
3.3 If physical therapy is performed
by other than a physician, a physician (or other authorized individual
professional provider acting within the scope of his/her license)
should refer the patient for treatment and supervise the physical
therapy.
3.4 Reimbursement for covered physical therapy
services is based on the appropriate CPT procedure codes for the
services billed on the claim.
3.5 Physical therapists are not
authorized to bill using Evaluation and Management (E/M) codes listed
in the Physician’s Current Procedural Terminology (CPT).
4.0 EXCLUSIONS
The following services are not covered:
4.1 Diathermy,
ultrasound, and heat treatments for pulmonary conditions.
4.2 General
exercise programs, even if recommended by a physician (or other
authorized individual professional provider acting within the scope
of their license).
4.3 Electrical nerve stimulation
used in the treatment of upper motor neuron disorders such as multiple
sclerosis.
4.4 Separate charges for instruction of the patient
and family in therapy procedures.
4.5 Repetitive exercise to improve
gait, maintain strength and endurance, and assistative walking such
as that provided in support of feeble or unstable patients.
4.6 Range of
motion and passive exercises which are not related to restoration
of a specific loss of function, but are useful in maintaining range
of motion in paralyzed extremities.
4.7 Maintenance therapy that does
not require a skilled level after a therapy program has been designed
(see
Section 18.1).
4.8 Services of chiropractors
and naturopaths whether or not such services would be eligible for benefits
if rendered by an authorized provider.
4.9 Acupuncture with or without
electrical stimulation.
4.10 Athletic training evaluation
(CPT procedure codes 97005 and 97006).
4.11 Sensory integration therapy
(CPT procedure code 97533) which may be considered a component of
cognitive rehabilitation is unproven.
Note: This policy does
not exclude multidisciplinary services, such as physical therapy, occupational
therapy, or speech therapy after traumatic brain injury, stroke
and children with an autistic disorder.
4.12 Nonsurgical spinal decompression therapy (including
Internal or Intervertebral Disc Decompression (IDD), Decompression
Reduction Stabilization (DRS), or Vertebral Axial Decompression (VAX-D)
therapy) provided by mechanical or motorized traction for the treatment
of low back and/or neck pain is unproven. The use of powered traction
devices (including, but not limited to, the Accu-SPINA™, VAX-D,
and DRX9000) are likewise unproven.
4.13 For beneficiaries under the age of three, services
and items provided in accordance with the beneficiary’s Individualized
Family Service Plan (IFSP) as required by Part C of the Individuals
with Disabilities Education Act (IDEA), and which are otherwise
allowable under the TRICARE Basic program or the Extended Care Health
Option (ECHO) but determined not to be medically or psychologically necessary,
are excluded.
4.14 For beneficiaries
aged three to 21, who are receiving special education services from
a public education agency, cost-sharing of outpatient physical therapy
services that are required by the IDEA and which are indicated in
the beneficiary’s Individualized Education Program (IEP), may not
be cost-shared except when the intensity or timeliness of physical
therapy services as proposed by the educational agency are not sufficient
to meet the medical needs of the beneficiary.
4.15 Low Level Laser Therapy (LLLT) (also known
as low level light therapy or cold laser therapy) for treatment
of soft tissue injuries, pain or inflammation is unproven.
4.16 Spinalator therapy and use of a Spinalator
Table for the treatment of neck and low back pain. Spinalator therapy
is defined as a type of traction that uses the patient’s weight
to create the traction force in the absence of any external pulling
force. The Spinalator Table is defined as a table with rollers that
applies consistent pressure and movement under the patient in the
absence of any external pulling devices.