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.
4.0 EXCLUSIONS
The following services are
not covered:
4.1 Diathermy, ultrasound, and
heat treatments for pulmonary conditions.
Ultrasonic diathermy,
also known as sustained acoustic medicine, for arthritis, chronic
pain, and soft-tissue injuries; this includes at-home, wearable
devices (sam® devices) manufactured by ZetrOZ Systems LLC.
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 assisted 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 codes 97169 - 97172).
4.11 Sensory Integration Therapy (SIT)
(CPT code 97533) is unproven.
SIT services are not payable separately
or when billed in conjunction with other therapies. For example:
SIT services provided during an otherwise covered multidisciplinary
therapeutic intervention or service; during physical therapy, occupational
therapy, or speech therapy; or as a component of cognitive rehabilitation,
are services for which TRICARE bundles payment into the payment
for other related services.
Note: This policy does not exclude
multidisciplinary services, such as physical therapy, occupational
therapy, or speech therapy.
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.
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), shall 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,
laser acupuncture, or cold
laser therapy, and photobiomodulation) for the treatment
of soft tissue injuries, pain or inflammation is unproven.
4.16 LLLT
(also known as low-level light therapy, laser acupuncture, cold
laser therapy, and photobiomodulation) for the treatment of arthritis
is unproven.
4.17 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.
4.18 Effective June 1, 2020, Transcutaneous
Electrical Nerve Stimulation (TENS) for the treatment of acute, subacute,
and chronic low back pain (LBP) is excluded from coverage.
• The contractor shall not cost-share
physical therapy visits where the sole treatment provided is TENS
for LBP.
• The contractor shall not cost-share
separate charges for TENS therapy provided during the course of
an otherwise-covered physical therapy visit.
• TENS units for home use, prescribed
during the course of physical therapy, for the treatment of LBP,
are not covered.
4.19 Dry Needling (DN) is considered
unproven.
Note: If a physical therapist provides
DN in the course of an otherwise-covered physical therapy session/visit, TRICARE
may cost-share the cost of the covered care; no separate reimbursement
is available for DN. Visits for the sole purpose of receiving DN
are not covered.
