Oscar Outpatient Physical Therapy & Occupational Therapy (CG044) Form

The Plan

Members may require physical therapy (PT) when it is prescribed by a qualified health professional to significantly restore or improve functioning, relieve disease symptoms, and prevent disability in individuals with acute and/or chronic disease. A PT treatment plan of care may consist of heat and cold therapy, electric stimulation, manual therapy, a variety of exercise regimens, functional training for ambulatory activities, and the development of a home exercise program. PT may only be performed by a qualified, licensed physical therapist or by a physical therapist assistant (PTA) under the supervision of a qualified, licensed physical therapist.

The Plan members may require occupational therapy (OT) when it is prescribed by a qualified health professional to significantly regain skills of daily living that have been lost or impaired through disease or injury. OT treatments are used for both rehabilitation and habilitation, and are designed with purposeful activities. OT may only be performed by a qualified, licensed occupational therapist, or by an occupational therapist assistant (OTA) under the supervision of a qualified, licensed occupational therapist.

PT and OT are often coordinated by a multidisciplinary team of licensed therapists, nurses, and prescribing clinicians. PT or OT is usually one of numerous components that are part of a multidisciplinary treatment plan of care following injury or the diagnosis of a chronic disease.¹

For home physical therapy, please refer to the Plan Clinical Guideline: Home Care - Physical Therapy (PT) and Occupational Therapy (OT) (CG021).

Definitions

"Physical Therapy (PT)"

Refers to supervised therapeutic procedures performed by licensed healthcare professionals which are intended to relieve disease symptoms, prevent disability and restore clinical function. PT is often one of many components in a multidisciplinary treatment plan following injury or in chronic disease. Physical therapy may include, but is not limited to:

• Ambulation and mobility training
• Gait and balance training
• Strength training
• Joint mobilization
• Neuromuscular reeducation
• Therapeutic exercises
• Assistive device and adaptive equipment training
• Orthotic or prosthetic training
• Manual therapy

"Occupational Therapy (OT)"

Refers to a therapeutic intervention program designed and supervised by a team of physicians and occupational therapists to assist members in regaining skills of daily living that have been lost or impaired. Such programs are individualized to each member to help improve quality of life by restoring independence. Occupational therapy may include, but is not limited to:

• Activities of Daily Living (ADL) training
• Muscle re-education
• Cognitive or neurodevelopmental training
• Perceptual motor training
• Fine motor coordination/strength training
• Assistive device and adaptive equipment training
• Environment modification recommendations and training
• Transfer training
• Functional mobility training

"Activities of Daily Living (ADLs)"

Are defined as routine activities that most healthy persons perform daily without requiring assistance. These include, but are not limited to: bathing, communication, transferring from bed to standing, wheelchair, or walker, dressing, feeding, grooming, mobility (ambulating), personal hygiene, self-maintenance, skin management, and toileting.

"Instrumental Activities of Daily Living (IADLs)"

Are defined as activities that may be performed daily but are not fundamental for daily functioning. These include, but are not limited to: the use of public² transportation, balancing a checkbook, community living activities, meal preparation, laundry, leisure activities and sports, and motor vehicle operation.

"Rehabilitative Treatments"

Are OT or PT treatments provided with the goal of restoring or improving upon functions that have been lost or impaired due to injury, disease, or congenital abnormality. Rehabilitative treatments are restorative and differentiated from "habilitative treatments" in that the individual has previously met these functional milestones but has lost them due to some process.

"Habilitative Treatments"

Are OT or PT treatments provided with the primary goal of developing skills needed to perform ADLs or IADLs which, as a result of injury, disease, or congenital abnormality, are not developed to the normal level of functioning. It is differentiated from rehabilitative treatment in that habilitative treatments are for individuals that have never met the initial development milestone.

"Custodial Care"or "Long-term Care"

Are non-skilled, personal care to maintain the member's ADLs or IADLS over a long-term duration and do not require oversight or skilled services by trained health professionals or technical personnel. These services are not part of a medical treatment plan for recovery, rehabilitation, habilitation, or improvement in sickness or injury. Custodial services may be provided in the home, assisted living facilities, or nursing homes, etc.

This type of custodial or long-term care typically does not apply for plan benefits, please see the member’s plan benefit.

Clinical Indications

General Criteria

Outpatient Physical Therapy and Occupational Therapy is considered for initial requests when ALL of the following criteria are met:

1. The treatment plan is prescribed and monitored by a licensed provider (MD, DO, PA, or NP) as per individual state law and must be provided by a licensed physical therapist or occupational therapist; and
2. Medical necessity criteria in the appropriate MCG Ambulatory Care > Rehabilitation > Physical or Occupational Therapy Services guideline is met; and
3. When relevant, medical necessity criteria in the appropriate MCG Ambulatory Care > Rehabilitation > Therapeutic Modalities guideline is met (e.g., aquatic therapy, transcutaneous electrical nerve stimulation, functional and neuromuscular electrical stimulation); and
4. Therapy is aimed at establishing or restoring function that was lost or impaired as a result of disease, injury, or procedure; and
5. Rehab potential is evident based on a review of the member’s condition, and the member’s function is not expected to improve in the absence of therapy; and
6. Improvement can be expected within 1 month of beginning therapy and with sustainable benefit in range of motion, strength, function, reduced pain level, and independence of ADLs; and
7. The written plan of care includes an initial evaluation and is sufficient to determine the necessity of therapy, including ALL of the following elements:
   • The diagnosis, the date of onset or exacerbation of the disorder/diagnosis, the duration, the severity, the anticipated course (stable, progressive or, improving), and the prognosis; and
   • Prior functioning level; and
   • Long-term and short-term goals that are specific, quantitative, objective, and attainable in no more than 3 months; and
   • The frequency and duration of proposed treatment; and
   • The specific treatment techniques and/or exercises to be used; and
   • Education to help the member to self-manage and continue exercises and pain management program (e.g., TENS) without supervision; and
   • Discharge plan; and
   • Re-evaluation performed at least monthly and the results as well as any proposed changes to address progress or lack thereof; and
8. Therapy is no more than 60 minutes per day, unless specifically justified and approved as part of the initial evaluation and treatment plan.

Duration of Therapy

The duration of therapy is dependent on the treatment plan of care and the severity of the member’s condition. The Plan utilizes MCG rehabilitation criteria for the recommended visits per episode.

Extension Requests

A Plan member who requires continued PT or OT, beyond the original treatment plan of care, may receive extended treatment when ALL of the following criteria are met:

1. A re-evaluation has been conducted within 30 days of the service dates; and
2. The member has shown progress and improvement upon successful completion of the original treatment plan of care; and
3. Further significant improvement can be expected and continuation of PT or OT services must require the supervision of a licensed physical therapist; and
4. The written plan of continued care includes a complete history and documentation of progress from the original written plan of care, the member continues to have goals, and the elements noted above in the Clinical Indications section above.

Members may receive continued PT or OT equivalent to a maximum of 50% of the original treatment plan of care, with documentation and justification from the provider and may be subject to further review.

An exception to the maximum amount of PT or OT can be made if medically necessary and determined by a qualified health professional(s) managing the Plan member's treatment plan.

Experimental or Investigational / Not Medically Necessary

Physical and occupational therapy should be discontinued when any ONE of the following is present:

• The member reaches the predetermined goals or skilled treatment is no longer required; or
• The member has reached maximum rehab potential; or
• The goals will not be met and there is no expectation of meeting them in reasonable time; or
• The member can safely and effectively continue their rehabilitation in a home exercise program or self-management program (maintenance); or
• The member's medical condition prevents further therapy; or
• The member refuses treatment.

Physical/Occupational Therapy is NOT considered medically necessary for the following:

• Asymptomatic members or those without an identifiable clinical condition; or
• Improvement in functioning is not expected over a reasonable and predictable period of time (i.e., a 'stable deficit'); or
• Cases of transient or easily reversible loss or reduction in function which could be reasonably expected to improve spontaneously as the member gradually resumes normal activities; or
• Long-term maintenance therapy, as it is aimed to preserve the present level of function or to prevent regression below an acceptable level of functioning; or
• Custodial or long-term care services; or
• General exercises to promote fitness or flexibility are not medically necessary; or
• Duplicative therapy services or programs; or
• Occupational or recreational programs aiming to augment or improve upon normal human functioning; this includes services considered as routine, educational, for employment or job training, or as part of a fitness or sports program; or
• Sports Rehabilitation where treatment is extended what is needed to improve above and beyond the normal ability to perform activities of daily living
• Vertebral axial decompression, as they are considered experimental or investigational, including but not limited to the following devices:
  • Decompression Reduction Stabilization (DRS) System
  • DRX 9000
  • DX2 Decompression System
  • IDD Therapy (Intervertebral Differential Dynamics Therapy)
  • Integrity Spinal Care System
  • Lordex Lumbar Spine System
  • MTD 4000 Mettler Traction Decompression System
  • SpineRx-LDM
  • VAX-D Spinal Decompression System
• Treatment modalities where the benefits of PT/OT are not adequately supported by peer literature or accepted standards of practice to be safe and effective and therefore, considered experimental or investigational include, but are not limited to:
  • Applied Functional Science
  • Augmented soft tissue mobilization is considered investigational due to limited evidence of improved outcomes over standard techniques for soft tissue mobilization
  • Biofeedback for anal/perianal/urethral sphincters due to lack of high grade quality of evidence to support at this time.
  • Driver/safety training
  • Equestrian therapy (hippotherapy)
  • Group therapy (criteria require individualized plans)
  • Hands-Free Ultrasound and Low-Frequency Sound (Infrasound)
  • Hivamat therapy (deep oscillation therapy)
  • Interferential stimulation or interferential current therapy is the superficial application of a medium-frequency alternating current, modulated to produce low frequencies up to 150 Hz and is considered experimental and investigational due to the lack of high grade quality literature. Devices such as neoGEN-Series System (RST-Sanexas) as a form of interferential current therapy for neuropathic pain provide ultra-high digital frequency to produce pulsed electronic signal energy waves that are delivered transcutaneously via contact electrodes. As per Hayes 2023, there are no relevant clinical studies, systematic reviews, or guidance documents supporting use of RST-Sanexas.
  • Kinesio taping for back pain or radicular pain is considered investigational and not clearly established in the literature
  • Low level laser therapy (LLLT)
  • Microcurrent electrical nerve stimulation (MENS)
  • Pilates, Tai Chi and Qi Gong
  • Sensory integrative techniques
  • The Interactive Metronome Program
  • MEDEK Therapy
  • McKenzie Method of Mechanical Diagnosis and Therapy
• Conditions where the benefits of PT/OT are not adequately supported by peer literature include, but are not limited to:
  • Constipation
  • Vaginismus
  • Social functioning
  • Sexual dysfunction (erectile dysfunction, premature ejaculation), extracorporeal shockwave therapy for erectile dysfunction
  • Scoliosis
  • TMJ pain