164 Form

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Medical Policy Dry Hydrotherapy for Chronic Pain Conditions Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 164 BCBSA Reference Number: 2.01.105 (For Plan internal use only) Related Policies
Transcutaneous Electrical Nerve Stimulation, #003 Dry Needling of Trigger Points for Myofascial Pain, #792 Trigger Point and Tender Point Injections, #604 Biofeedback as a Treatment of Chronic Pain, #210 Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain, #517 Manipulation Under Anesthesia, #483 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

The use of dry hydrotherapy massagers for the treatment of chronic pain conditions is considered INVESTIGATIONAL.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service.

CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

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Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

CPT Codes There is no specific CPT code for this service. Description Dry hydrotherapy, also known as hydromassage or aqua massage, is a massage treatment modality that circulates streams of heated, pressurized water in a self-contained device such as a bed or chair. The individual remains clothed and dry as they sit or lie on top of a waterproof barrier containing rotating and pulsating interior jets. Purported benefits of dry hydrotherapy include alleviation of pain, increased blood circulation, improved range of motion, deep relaxation, and reduction of stress and anxiety. Use of dry hydrotherapy has also been suggested to reduce the need for other interventions, by combining the effects of traditional wet hydrotherapy, massage therapy, acupressure, heat therapy, soft tissue manipulation, and trigger point therapy without the need for additional health staff.

Specific physiological effects claimed on the Sidmar manufacturer site for its hydromassage tables include purported physiological effects stemming from application of radiant heat and massage.1, Purported physiologic effects of radiant heat include analgesic, antispasmodic, decongestive, sedative, and vasodilatory properties, leading to reduced pain, increased relaxation, enhanced capillary blood flow, decreased spasticity, tenderness, and spasm, and increased rates of healing. Purported benefits of massage include increased local blood supply, increased lymphatic drainage and reduction of swelling, muscle relaxation, prevention of adhesions and fibrosis, decreased tendency toward muscle atrophy, and pain reduction and increased ease of mobility.

Summary
Dry hydrotherapy, also known as hydromassage or aqua massage, is a massage treatment modality that circulates heated, pressurized water in a self-contained device such as a bed or chair. The individual remains clothed and dry as they sit or lie on top of a waterproof barrier containing rotating and pulsating interior jets. Purported benefits of dry hydrotherapy include alleviation of pain, increased blood circulation, improved range of motion, and decreased need for other interventions.

Summary of Evidence For individuals with chronic pain conditions (eg, musculoskeletal, neuropathic, and mixed pain conditions) who receive dry hydrotherapy, there are no published, peer-reviewed studies. Relevant outcomes are symptoms, functional outcomes, quality of life, medication use, and resource utilization. A health technology assessment released in 1998 for the AquaMED device also failed to identify published research to support claims that dry hydrotherapy can take the place of multiple modalities or that it provides any durable health benefits. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 1/2025 Annual policy review. References updated. Policy statements unchanged. 1/2024 Annual policy review. References updated. Policy statements unchanged. 1/2023 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
11/2022 New medical policy describing investigational indications. Effective 11/1/2022. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines

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Clinical Exception Process Medical Technology Assessment Guidelines References

1. Sidmar. Healthcare Data. 2023; https://sidmar.com/healthcare/healthcare-data/. Accessed October 28, 2024.
2. Washington State Department of Labor & Industries. AquaMED Technology Assessment. 1998; https://www.lni.wa.gov/patient-care/treating-patients/treatment-guidelines-and- resources/_docs/AquaMedTA.pdf. Accessed October 28, 2024.
3. Chiropractic Economics. AquaMED and HydroMassage announce brand integration. January 28, 2009; https://www.chiroeco.com/aquamed-and-hydromassage-announce-brand-integration/. Accessed October 28, 2024.
4. HydroMassage. HydroMassage Benefits: Ways Water Massage Can Improve Wellness & Recovery. January 20, 2022; https://www.hydromassage.com/blog/hydromassage-benefits-for-wellness- recovery/. Accessed October 28, 2024.
5. National Institute for Health and Care Excellence (NICE). NICE guideline [NG65]. Spondyloarthritis in over 16s: diagnosis and management. February 28, 2017; https://www.nice.org.uk/guidance/ng65. Accessed October 28, 2024.