Medical Policy: 08.03.03
Original Effective Date: May 2002
Reviewed: July 2015
Revised: December 2004
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Physical therapy is defined as the care and services provided by a physical therapist or a physical therapist assistant under the direction and supervision of a physical therapist. Through the patient/client management elements of examination, evaluation, diagnosis, prognosis, and intervention, physical therapists provide services to patients/clients who have impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, congenital anomaly, or prior therapeutic intervention.
See also Medical Policy 01.01.20 Disposable Non-Powered Mechanical Negative Pressure Wound Care System or Single Use Non-Electrically Powered Negative Pressure Wound Care Therapy
Physical therapy services are considered a covered benefit when all of the following criteria have been met:
- Meet the functional needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomaly, or prior therapeutic intervention;
- Achieve a specific diagnosis-related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time;
- Provide specific, effective, and reasonable treatment for the patient's diagnosis and physical condition;
- Will be delivered by a qualified provider of physical therapy services. A qualified provider is one who is licensed where required and performs within the scope of licensure;
- Require the judgment, knowledge, and skills of a qualified provider of physical therapy services due to the complexity and sophistication of the therapy and the physical condition of the patient.
- Are consistent with the current edition of the Physical Medicine Guidelines published by Wellmark Blue Cross Blue Shield of Iowa/South Dakota.
Physical therapy is not medically necessary under the following circumstances:
- If the service is excluded from the subscriber benefit certificate;
- The services are determined to be not medically necessary;
- If the service is considered investigational or experimental. A service is considered investigational and experimental when the service, procedure, drug, or treatment has progressed to limited human application, but has not achieved recognition as being proven and effective in the clinical setting. Wellmark Blue Cross Blue Shield of Iowa and South Dakota determines whether a service is investigational or experimental based on the current literature;
- The service is duplicative of services given by the same or another provider;
- The services are considered non-skilled and do not require the skills of the physical therapist or physical therapist assistant and therefore are not medically necessary e.g., hot or cold packs;
- The services are considered to be a maintenance program which consists of activities that preserve the patient's present level of function and prevents regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is measurable or expected to occur.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- Physical therapy services are found in the Physical Medicine and Rehabilitation section of the AMA Current Procedural Terminology manual. Codes used to bill for physical therapy services are most commonly 97001 through 97799. Appropriate CPT codes or Alpha Numeric (HCPCS level 2) codes should be accompanied by the correct Revenue or ICD-9 diagnostic codes.
- Specific service limitations are found in Wellmark's Physical Medicine Guidelines
- The Guide to Physical Therapist Practice (2nd Edition), Physical Therapy: 2001; 81: 9-744.
- Physical Medicine Guidelines (June 2014 edition), Wellmark Blue Cross Blue Shield of Iowa and South Dakota.
- Weiss HR. Inclusion criteria for physical therapy intervention studies on scoliosis- a review of the literature. Stud Health Technol Inform. 2012;176:350-3.
- Franki I, Desloovere K, De Cat J, et al. The evidence-base for basic physical therapy techniques targeting lower limb function in children with cerebral palsy: a systematic review using the International Classification of Functioning, Disability and Health as a conceptual framework. J Rehabil Med. 2012 May;44(5):385-95.
- FitzGerald MP, Payne CK, Lukacz ES, et al. Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. J Urol. 2012 Jun;187(6):2113-8.
- Delitto A, George SZ, Van Dillen L, et al. Low Back Pain- Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2012;42(4):A1-A57.
- Scottish Intercollegiate Guidelines Network (SIGN). Brain injury rehabilitation in adults. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2013 Mar. 68 p.
Date Reason Action
December 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
October 2012 Annual review Policy renewed
September 2013 Annual review Policy renewed
August 2014 Annual review Policy renewed
July 2015 Annual review Policy renewed
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.