Anthem Blue Cross Connecticut CG-MED-91 Remote Therapeutic and Physiologic Monitoring Services Form

Remote therapeutic monitoring (RTM) refers to the remote monitoring and management of therapy services, for example, monitoring of respiratory or musculoskeletal status, and medication and therapy adherence and response. RTM involves remote managing and collection of non-physiological patient data.

Remote physiologic monitoring (RPM) refers to the monitoring of physiological data, for example, weight, blood pressure, pulse oximetry, respiratory flow rate, as well as associated physiologic monitoring treatment management services.

For information about other monitoring services see:

• CG-DME-08 Infant Home Apnea Monitors
• CG-DME-10 Durable Medical Equipment
• CG-DME-30 Prothrombin Time Self-Monitoring Devices
• CG-DME-42 Continuous Glucose Monitoring Devices

Clinical Indications

Medically Necessary:

Remote therapeutic monitoring (RTM) in a non-healthcare setting is considered medically necessary when clinical records document the rationale for monitoring including ALL of the following:

1. RTM is clinically appropriate, in terms of type, quantity, frequency, extent, site and duration and is considered effective for the individual’s illness, injury or disease and in accordance with generally accepted standards of medical practice*; and
2. RTM data is being regularly assessed to detect acute changes in clinical status and prompt intervention; and
3. RTM is not primarily for the convenience of the individual, physician, caregiver, or other health care provider; and
4. The individual is at risk of clinically significant changes in medical status which warrant enhanced monitoring based on current status and instability of the underlying clinical condition; and
5. The individual is unable to access regularly scheduled outpatient clinical care or therapeutic monitoring is required between visits due to potential changes in medical status; and
6. Monitoring is reasonably likely to prevent avoidable deterioration in the clinical condition and/or other adverse events relating to the underlying clinical condition.

Remote physiologic monitoring (RPM), in a non-healthcare setting is considered medically necessary when clinical records document the rationale for monitoring including ALL of the following:

1. RPM involves an FDA-recognized medical device that directly measures member physiologic data (for example, sphygmomanometer, pulse oximeter, heart rate monitor, glucometer, thermometer, weight scale, respiratory flow rate monitor) used to develop and manage a treatment plan related to a chronic and/or acute health illness or condition; and
2. RPM is clinically appropriate, in terms of type, quantity, frequency, extent, site and duration and is considered appropriate for the individual’s illness, injury or disease and in accordance with generally accepted standards of medical practice*; and
3. RPM data is being assessed to detect acute changes in clinical status and prompt intervention; and
4. RPM is not primarily for the convenience of the individual, physician, caregiver, or other health care provider; and
5. The individual is at risk of clinically significant changes in medical status which warrant enhanced monitoring based on current status and instability of the underlying clinical condition; and
6. The individual is unable to access regularly scheduled outpatient clinical care or physiological monitoring is required between visits due to potential changes in medical status; and
7. Monitoring is reasonably likely to prevent avoidable deterioration in the clinical condition and/or other adverse events relating to the underlying clinical condition.

Not Medically Necessary:

RTM or RPM is considered not medically necessary when similar services are being provided concurrently, for example, home health services.

RTM or RPM is considered not medically necessary when the criteria above have not been met.

*Generally accepted standards of medical practice means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations and the views of physicians practicing in relevant clinical settings.