Description

Physical therapy (PT) is the treatment of disorders or injuries using physical methods or modalities. A PT modality is often defined as any physical agent applied to produce therapeutic changes to biologic tissues. Modalities that are generally accepted for use include exercises, thermal, cold, ultrasonic or electric energy devices. Due to the passive nature of therapeutic modalities, they are generally used to enable the individual to take part in active aspects of therapy.

PT may be indicated for treatment of muscle weakness, limitations in the range of motion, neuromuscular conditions, musculoskeletal conditions, lymphedema and for selected training of an individual in specific techniques and exercises for their own continued use at home.

Physical Therapy and Occupational Therapy Effective Date: 09/12/2023

Revision Date: 09/12/2023

Review Date: 06/22/2023

Policy Number: HUM-0366-033

Page: 2 of 41

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Therapeutic procedures are intended as a means of effecting change using clinical skills and/or techniques and/or services whose goal is the improvement of function. PT procedures in general include therapeutic exercises and joint mobilization. These have generally been shown to be one set of effective means of treating aspects of many musculoskeletal conditions.

Medically necessary PT services must be restorative in nature or for the specific purposes of designing and teaching a maintenance program for the individual to carry out at home. The services must also relate to a written treatment plan and be of the level of complexity that requires the judgment, knowledge and skills of a physical therapist (or medical doctor/doctor of osteopathy) to perform and/or directly supervise.

The amount, frequency and duration of PT services must be seen as medically appropriate for the specific treatment regimen and be performed by a physical therapist.

A qualified physical therapist, for benefit coverage purposes, is an individual who is licensed as a physical therapist by the state in which he or she is practicing. A physical therapist assistant (PTA) is an individual who is licensed as a PTA, if applicable, by the state in which he or she is practicing. The services of a PTA must be supervised by a licensed physical therapist at a level of supervision determined by state law or regulation.

Occupational therapy (OT)

is a form of rehabilitation therapy involving the treatment of neuromuscular and other dysfunction through the use of specific tasks or goal-directed activities to improve an individual’s functional performance. Therapy programs are designed to improve the individual’s quality of life through the recovery of specific competencies, maximizing independence and the prevention of specific illness or disability.

OT includes helping an individual learn or relearn specific daily living skills (eg, basic activities of daily living [ADL]) such as dressing, eating, personal hygiene, self-care and mobility/transfers. OT also includes specific task oriented therapeutic activities designed to restore physical function of the shoulder, elbow, wrist and/or hand that has been lost as a result of illness or injury. Occupational therapy can include the

Physical Therapy and Occupational Therapy Effective Date: 09/12/2023

Revision Date: 09/12/2023

Review Date: 06/22/2023

Policy Number: HUM-0366-033

Page: 3 of 41

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Design, fabrication and fitting/maintenance of orthotics and related self-help devices including the fitting/fabrication of splints for the upper extremity. Medically necessary OT services must relate to a written treatment plan and be of the level of complexity that requires the judgment, knowledge and skills of an occupational therapist (or medical doctor/doctor of osteopathy) to perform and/or directly supervise these services. The amount, frequency and duration of occupational therapy services must be medically appropriate for the specific treatment regimen and be performed by an occupational therapist.

A qualified occupational therapist, for benefit coverage purposes, is an individual who is licensed as an occupational therapist by the state in which he or she is practicing. An occupational therapy assistant (OTA) is an individual who is licensed as an OTA, if applicable, by the state in which he or she is practicing. The services of an OTA must be supervised by a licensed occupational therapist at a level of supervision determined by state law or regulation.

PT and OT services may be considered rehabilitative or habilitative:

• Rehabilitative services refers to PT and/or OT services that help an individual regain or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled.
• Habilitative services refers to PT and/or OT services that help an individual keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking at the expected age.

For information regarding coverage determination/limitations not addressed in this medical coverage policy, please refer to the following:

Treatment Corresponding Medical Coverage Policy

• Biofeedback Biofeedback
• Cardiac rehabilitation Cardiac Rehabilitation
• Cold and heat therapy devices Cold Therapy Devices/Heating Devices/Combined Heat and Cold Therapy

Physical Therapy and Occupational Therapy Effective Date: 09/12/2023

Revision Date: 09/12/2023

Review Date: 06/22/2023

Policy Number: HUM-0366-033

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Complementary or alternative medicine (CAM) Complementary and Alternative Medicine

• Low level laser or high power laser therapy Low Level Laser and High Power Laser Therapy

Coverage Determination

REHABILITATIVE PHYSICAL THERAPY AND OCCUPATIONAL THERAPY

Any state mandates for rehabilitative PT or OT take precedence over this medical coverage policy.

Refer to specific certificate language regarding rehabilitative physical and/or occupational therapy.

Most certificates limit the duration or number of visits.

General Criteria for Rehabilitative PT and/or OT

Humana members may be eligible under the Plan for rehabilitative PT and/or OT when the following criteria are met:

• The participating physician or licensed health care practitioner has determined that the individual’s condition can improve significantly based on physical measures (eg, active range of motion [AROM], strength, function or subjective report of pain level) within one month of the date that therapy begins or the therapy services proposed must be necessary for the establishment of a safe and effective maintenance program that will be performed by the individual without ongoing skilled therapy services. These services must be proposed for the treatment of a specific illness or injury; AND
• Rehabilitative PT and/or OT may be performed for conditions related to a defect, developmental delay*, functional impairment** or pain as evidenced by supporting documentation recorded in medical records submitted for review; AND
  *Developmental delay describes the condition in which a child is not developing and/or achieving skills according to the expected time frame.
  **Functional impairment describes a direct and measurable reduction in physical performance of an organ or body part.
• The rehabilitative PT and/or OT services provided are intended to cover only episodes of therapy for situations where there must be a reasonable expectation that an individual’s condition will improve significantly in a reasonable and generally predictable period of time; AND
• Rehabilitative PT and/or OT services must be ordered by a physician or other licensed health care practitioner and performed by a duly licensed and certified, if applicable, PT/OT provider. All services provided must be within the applicable scope of practice for the provider in their licensed jurisdiction where the services are provided; AND require that they are performed by a licensed professional therapist or provided under their direct supervision by a licensed ancillary person as permitted under state laws. Services may be provided personally by physicians and performed by personnel under their direct supervision as permitted under state laws. As physicians are not licensed as physical therapists or occupational therapists, they may not directly supervise physical therapist assistants or occupational therapy assistants; AND
• Rehabilitative PT and/or OT must be provided in accordance with an ongoing, individualized written plan of care that is reviewed with and approved by the treating physician in accordance with applicable state laws and regulations. The PT and/or OT plan of care should be of such sufficient detail and include appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment.

Physical Therapy and Occupational Therapy Effective Date: 09/12/2023

Revision Date: 09/12/2023

Review Date: 06/22/2023

Policy Number: HUM-0366-033

Page: 5 of 41

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Physical Therapy and Occupational Therapy Effective Date: 09/12/2023

Revision Date: 09/12/2023

Review Date: 06/22/2023

Policy Number: HUM-0366-033

Page: 6 of 41

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

This information should include at least the following:

• PT and/or OT evaluation; AND
• Short- and long-term goals that are specific, quantifiable (measurable) and objective; AND
• Reasonable estimate as to the time when these goals will be achieved; AND
• Specific PT and/or OT techniques, treatments or exercises to be used; AND
• Frequency and duration of the treatments provided must be reasonable and customary under the generally accepted standards of practice for PT and/or OT; AND

The signatures and professional license designations (and license numbers) for the treating therapist and treating physician must be affixed to the evaluation and/or ongoing treatment reports. The individual must be re-evaluated at least monthly and the results of these evaluations recorded in a standard format. The individual’s progress towards achieving the stated goals must be assessed and changes made, if needed, in the treatment program as a result of the evaluations; AND

Rehabilitative PT and/or OT services in excess of 60 minutes per day are generally not demonstrated to have additional medical benefit in an outpatient setting. Specific situations for which more than 60 minutes per day of PT and/or OT must be justified by appropriate documentation including demonstrated efficacy of these treatments in this intensity in the peer-reviewed professional literature; AND

Rehabilitative PT and/or OT are generally covered for an individual with eligible conditions that require improvement in the ADL. These include, but may not be limited to:

• Bathing; OR
• Communication; OR
• Dressing; OR
• Feeding; OR
• Grooming; OR
• Mobility; OR
• Personal hygiene; OR
• Self-maintenance; OR
• Skin management; OR
• Toileting; AND

Rehabilitative PT and/or OT may be appropriate for acute episodes or significant exacerbations of long standing/chronic/previously known medical or surgical conditions; AND

establishment of a safe and effective maintenance program (to be carried out by the individual or caretakers) that is required in connection with the generally accepted treatment of a condition that is eligible under the Plan. Limited, short- term episodes of therapy for services for a progressive degenerative disease may be intermittently eligible if they are for the determination of the need for specific assistive equipment and/or to establish/re-establish a maintenance program for the condition under treatment. A maintenance program is NOT generally eligible under the Plan; AND

Skilled rehabilitative services that are required specifically for the individual’s safety may be eligible if they involve the use of complex, sophisticated therapy procedures and it is reasonable and necessary to have the services of a skilled physical therapist and/or occupational therapist to specifically provide these services in a safe and effective manner; AND

Fluidized therapy (Fluidotherapy) as an alternative to other heat therapy modalities in the treatment of acute or subacute traumatic or nontraumatic musculoskeletal disorders of the extremities; AND

• Maximum duration of treatment is four weeks; AND

Physical Therapy and Occupational Therapy Effective Date: 09/12/2023

Revision Date: 09/12/2023

Review Date: 06/22/2023

Policy Number: HUM-0366-033

Page: 7 of 41

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Physical Therapy and Occupational Therapy Effective Date: 09/12/2023

Revision Date: 09/12/2023

Review Date: 06/22/2023

Policy Number: HUM-0366-033

Page: 8 of 41

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• The following contraindications to fluidized therapy are not present:
  • Severe circulatory obstruction disorders (eg, arterial, lymphatic or venous disorders); OR
  • Systemic infectious diseases (eg, diabetes mellitus, hypertension or influenza); OR
• Gait analysis and/or computerized gait analysis for the evaluation of an individual with cerebral palsy prior to a planned surgery (and may be repeated no more than once postoperatively, if necessary)

Coverage Limitations

REHABILITATIVE PHYSICAL THERAPY AND OCCUPATIONAL THERAPY

Humana members may NOT be eligible under the Plan for rehabilitative physical and/or occupational therapy services for any indications or treatment techniques or modalities other than those listed above including, but not limited to the following:

• Aquatic therapy; OR
• Augmented soft tissue mobilization (ASTM); OR
• Back-to-school and/or return-to-work/reintegration or vocational programs including work-hardening (may be excluded by certificate); OR
• Care and treatment provided by and/or in specialized clinics (eg, athletic performance enhancement, behavioral or conduct disorders, sexual performance or weight loss); OR
• Cost of supplies (eg, electrodes, hand putty, theraband) used in furnishing physical and occupational therapy is included in the general services with which they are associated. Separate coverage may exist for off-the-shelf splints, custom fabricated splints and other designated items; OR

Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
Revision Date: 09/12/2023
Review Date: 06/22/2023
Policy Number: HUM-0366-033
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Deep massage or related therapies to release or otherwise treat adhesions or similar problems of deep internal organs and/or structures; OR
• Duplicative therapy – receiving both rehabilitative OT and PT for the same clinical condition or problem. Other examples include, but may not be limited to microwave or diathermy, neuromuscular re-education or therapeutic exercises, kinetic activities or therapeutic exercises and functional activities or ADL; OR

If both therapies are provided, the treatment programs must be separately determined and part of specific, separate written treatment plans; the therapies must provide significantly different treatments and not be seen as generally duplicating each other.

• Education and/or training or other medical/therapy services provided by the individual’s parent, spouse, brother, sister or child; OR
• Enrollment in a health, athletic or similar club; OR
• Equestrian/hippotherapy and other similar neuromuscular exercise/training programs; OR
• General conditioning, even if requested after an illness or injury; OR
• Graston technique; OR
• Group therapy sessions (as this is not one-on-one and personalized to the specific individual’s needs); OR
• Hands-free ultrasound; OR
• Interactive metronome therapy; OR
• Internal manipulation (eg, transrectal, transvaginal) for conditions including, but may not be limited to:
  • Chronic pelvic pain; OR
  • Interstitial cystitis; OR

Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
Revision Date: 09/12/2023
Review Date: 06/22/2023
Policy Number: HUM-0366-033
Page: 10 of 41

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Pudendal neuralgia; OR
• Vulvodynia; OR
• Kinesio taping; OR
• Lactation counseling and services related to the postpartum condition when provided by or under the direction of physical therapists or occupational therapists; OR
• Maintenance care consists of activities that generally are intended to preserve the individual's present level of function and/or prevent regression of that level of function including, but may not be limited to the following (may be excluded in the certificate):
• Maintenance begins when the therapeutic goals of the treatment program are achieved or when no further significant progress is made or reasonably seen as occurring; AND
• Individual has achieved generally accepted normal levels of function and/or muscle strength and has reached a plateau (generally a period of four weeks or less, depending on the specific condition and/or individual situation); OR
• MEDEK therapy, also known as Cuevas Medek Exercises (CME); OR
• Myofascial release (MFR), also known as active release technique (ART); OR
• Nonskilled services – certain types of treatment that do not generally require the skills of a qualified physical therapist or occupational therapist. Nonskilled services include, but are not limited to, (1) passive range of motion (PROM) treatment which is not specifically part of a restorative program related to a loss of function and (2) services which maintain function by using routine, repetitive and reinforced procedures after initial teaching of the individual has taken place. These also include most situations where general conditioning, recovery from an acute medical/surgical illness that caused deconditioning or increased general ability to exercise or walk are undertaken. Services that can be safely and effectively furnished by nonskilled (nonlicensed physical therapists and
• Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
  Revision Date: 09/12/2023
  Review Date: 06/22/2023
  Policy Number: HUM-0366-033
  Page: 11 of 41
• Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
• occupational therapists or their assistants under appropriate supervision) personnel are nonskilled services; OR
• Orthoptics, vision training and related services (may be excluded by certificate); OR
• Phonophoresis; OR
• Portable (home) ultrasound devices; OR
• Relaxation therapy and/or massage therapy (if not delivered by a physical therapist or occupational therapist and is unrelated to a comprehensive treatment program); OR
• Remote body and limb kinematic measurement-based therapy (eg, interactive rehabilitation exercise devices, MindMotion GO); OR
• Sensory integration therapy; OR
• Services and supplies for treatment of temporomandibular joint (TMJ) dysfunction and craniomandibular joint (CMJ) disorders. Treatment of these disorders is generally excluded by certificate, please refer to the member's individual certificate; OR
• Services associated with or for the treatment of learning disabilities; OR
• Services deemed not medically necessary – Rehabilitative PT and/or OT for an individual whose condition is neither regressing nor improving, is not medically necessary.

It is the intent of the PT and OT coverage to have the individual receive those services that are medically necessary, who show demonstrated improvement over a reasonable period of time, consistent with the condition under treatment and to achieve the stated treatment goals, consistent with the available benefits under the Plan; OR

• Services related to activities for the general good and welfare of the individual such as exercises to promote overall fitness and flexibility, activities to provide diversion or general motivation; OR

Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
Revision Date: 09/12/2023
Review Date: 06/22/2023
Policy Number: HUM-0366-033
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Services which appear to be for the individual’s and/or therapist’s convenience or to treat conditions or illnesses that are not covered under the Plan; OR
• Therapy intended to effect improvement or restoration of function where an individual suffers a transient and easily reversible loss of function which could be reasonably expected to improve spontaneously as the individual gradually resumes normal activities; OR
• Treatments and/or therapies that are intended to specifically improve what are known as Instrumental Activities of Daily Living (IADL); including, but may not be limited to:
  • Community living skills including balancing a checkbook, use of public transportation; OR
  • Home management skills including meal preparation, laundry; OR
  • Leisure activities including hobbies, sports or recreation of all types even if suggested as part of a PT or OT treatment plan; OR
  • Motor vehicle driving evaluations and driving instruction. This includes automobiles, trucks, motorcycles and bicycles; OR
  • Personal health management; OR
  • Personal safety preparedness; OR
• Treatments for handwriting problems in children and/or adults; OR
• Treatments for neurobehavioral and/or neuropsychiatric conditions provided by physical therapists and/or occupational therapists; OR
• Treatments for sexual dysfunction; OR
• Treatments for sports-related rehabilitation^ or other similar avocational activities including, but may not be limited to:

  Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
  Revision Date: 09/12/2023
  Review Date: 06/22/2023
  Policy Number: HUM-0366-033
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  Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Baseball pitching/throwing; OR
  • Cheerleading; OR
  • Golfing; OR
  • Martial arts of all types; OR
  • Organized football, baseball, basketball, soccer, lacrosse, swimming, track and field, etc.
  • at a college, high school, other school or community setting; OR
  • Personal return to running rehabilitation; OR
  • Professional and amateur tennis; OR
  • Professional and amateur/hobby/academic dance; OR
  • Weightlifting and similar activities; OR

  ^Refers to continued treatment for sports related injuries in an effort to improve above and beyond normal ability to perform ADLs; it is not intended to return the individual to their previous (or improved) level of sports competition or capability.

  • Treatments for the consequences of services/procedures/treatments that are noncovered under the Plan are also not covered; OR
  • Treatments generally known as early intervention even if not specifically called by this name, even if not formally given at a designated or otherwise credentialed or licensed early intervention center or provider

  All other indications, treatment techniques or modalities are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

  Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
  Revision Date: 09/12/2023
  Review Date: 06/22/2023
  Policy Number: HUM-0366-033
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  Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Dry hydrotherapy, also known as aqua massage, hydromassage or water massage (eg, Aqua Massage, Aqua MED, H2O Massage System and Hydrotherapy Tables); OR
  • Dry needling (needle insertion without injection); OR
  • Nonimmersive, semi-immersive or fully immersive virtual reality based therapy (eg, exergaming); OR
  • Virtual reality facilitated gait training (eg, GaitBetter)

  These are considered experimental/investigational and are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

  Coverage Determination

  HABILITATIVE PHYSICAL THERAPY AND OCCUPATIONAL THERAPY

  Any state mandates for habilitative PT or OT take precedence over this medical coverage policy.

  Refer to specific certificate language regarding habilitative physical and/or occupational therapy. Most certificates limit the duration or number of visits.

  General Criteria for Habilitative PT and/or OT Humana members may be eligible under the Plan for habilitative PT and/or OT when the following criteria are met:

  that the individual's condition can improve or stabilize based on physical measures (eg, active range of motion [AROM], strength, function or subjective report of pain level) within a reasonable and generally predictable period of time or the therapy services proposed must be necessary for the establishment of a safe and effective maintenance program that will be performed by the individual without ongoing skilled therapy services. These habilitative services must be proposed for the treatment of a specific illness or injury; AND

  Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
  Revision Date: 09/12/2023
  Review Date: 06/22/2023
  Policy Number: HUM-0366-033
  Page: 15 of 41

  Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

  Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • The habilitative PT and/or OT services provided are intended to cover only episodes of therapy for situations where there must be a reasonable expectation that an individual's condition will improve in a generally predictable period of time; AND
  • Habilitative PT and/or OT may be provided for an individual with a congenital anomaly*, defect or developmental delay** as evidenced by supporting documentation recorded in medical records submitted for review; AND
    *Congenital anomaly describes an abnormality of the body that is present from the time of birth.
    **Developmental delay describes the condition in which a child is not developing and/or achieving skills according to the expected time frame
  • Habilitative PT and/or OT services must be ordered by a physician or other licensed health care practitioner and performed by a duly licensed and certified, if applicable, PT/OT provider. All services provided must be within the applicable scope of practice for the provider in their licensed jurisdiction where the services are provided; AND
  • require that they are performed by a licensed professional therapist or provided under their direct supervision by a licensed ancillary person as permitted under state laws. Services may be provided personally by physicians and performed by personnel under their direct supervision as permitted under state laws. As physicians are not licensed as physical therapists or occupational therapists, they may not directly supervise physical therapist assistants or occupational therapy assistants; AND
  • Habilitative PT and/or OT must be provided in accordance with an ongoing, individualized written plan of care that is reviewed with and approved by the treating physician in accordance with applicable state laws and regulations. The PT and/or OT plan of care should be of such sufficient detail and include appropriate objective and subjective data to demonstrate the medical necessity

  Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
  Revision Date: 09/12/2023
  Review Date: 06/22/2023
  Policy Number: HUM-0366-033
  Page: 16 of 41

  Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  of the proposed treatment. This information should include at least the following:

  1. PT and/or OT evaluation; AND
  2. Short- and long-term goals that are specific, quantifiable (measurable) and objective; AND
  3. Reasonable estimate as to the time when these goals will be achieved; AND
  4. Specific PT and/or OT techniques, treatments or exercises to be used; AND
  5. Frequency and duration of the treatments provided must be reasonable and customary under the generally accepted standards of practice for PT and/or OT; AND

  The signatures and professional license designations (and license numbers) for the treating therapist and treating physician must be affixed to the evaluation and/or ongoing treatment reports. The individual must be re-evaluated at least monthly and the results of these evaluations recorded in a standard format. The individual's progress towards achieving the stated goals must be assessed and changes made, if needed, in the treatment program as a result of the evaluations; AND

  Habilitative PT and/or OT services in excess of 60 minutes per day are generally not demonstrated to have additional medical benefit in an outpatient setting.

  Specific situations for which more than 60 minutes per day of PT and/or OT must be justified by appropriate documentation including demonstrated efficacy of these treatments in this intensity in the peer-reviewed professional literature; AND

  • Habilitative PT and/or OT are generally covered for an individual with eligible conditions that require improvement in the ADL. These include, but may not be limited to:
  • Bathing; OR
  • Communication; OR

  Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
  Revision Date: 09/12/2023
  Review Date: 06/22/2023
  Policy Number: HUM-0366-033
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  • Dressing; OR
  • Feeding; OR
  • Grooming; OR
  • Mobility; OR
  • Personal hygiene; OR
  • Self-maintenance; OR
  • Skin management; OR
  • Toileting; AND

  Habilitative PT and/or OT may be appropriate for acute episodes or significant exacerbations of long standing/chronic/previously known medical or surgical conditions; AND

  establishment of a safe and effective maintenance program (to be carried out by the individual or caretakers) that is required in connection with the generally accepted treatment of a condition that is eligible under the Plan. Limited, short- term episodes of therapy for services for a progressive degenerative disease may be intermittently eligible if they are for the determination of the need for specific assistive equipment and/or to establish/reestablish a maintenance program for the condition under treatment; AND

  Skilled habilitative services that are required specifically for the individual’s safety may be eligible if they involve the use of complex, sophisticated therapy procedures and it is reasonable and necessary to have the services of a skilled physical therapist and/or occupational therapist to specifically provide these services in a safe and effective manner; AND

  Fluidized therapy (Fluidotherapy) as an alternative to other heat therapy modalities in the treatment of acute or subacute traumatic or nontraumatic musculoskeletal disorders of the extremities; AND

  • Maximum duration of treatment is four weeks; AND
  • If the following contraindications to fluidized therapy are not present:

  Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
  Revision Date: 09/12/2023
  Review Date: 06/22/2023
  Policy Number: HUM-0366-033
  Page: 18 of 41

  Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

  Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Severe circulatory obstruction disorders (eg, arterial, lymphatic or venous disorders); OR
  • Systemic infectious diseases (eg, diabetes mellitus, hypertension or influenza); OR
  • Gait analysis and/or computerized gait analysis for the evaluation of an individual with cerebral palsy prior to a planned surgery (and may be repeated no more than once postoperatively, if necessary)

  Coverage Limitations

  HABILITATIVE PHYSICAL THERAPY AND OCCUPATIONAL THERAPY

  Humana members may NOT be eligible under the Plan for habilitative physical and/or occupational therapy services for any indications or treatment techniques or modalities other than those listed above including, but not limited to the following:

  • Aquatic therapy; OR
  • Augmented soft tissue mobilization (ASTM); OR
  • Back-to-school and/or return-to-work/reintegration or vocational programs including work-hardening (may be excluded by certificate); OR
  • Care and treatment provided by and/or in specialized clinics (eg, athletic performance enhancement, behavioral or conduct disorders, sexual performance or weight loss); OR
  • Cost of supplies (eg, electrodes, hand putty, theraband) used in furnishing physical and occupational therapy is included in the general services with which they are associated. Separate coverage may exist for off-the-shelf splints, custom fabricated splints and other designated items; OR
  • Deep massage or related therapies to release or otherwise treat adhesions or similar problems of deep internal organs and/or structures; OR

  Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
  Revision Date: 09/12/2023
  Review Date: 06/22/2023
  Policy Number: HUM-0366-033
  Page: 19 of 41

  Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Duplicative therapy – receiving both habilitative PT and OT for the same clinical condition or problem. Other examples include, but may not be limited to microwave or diathermy, neuromuscular re-education or therapeutic exercises, kinetic activities or therapeutic exercises and functional activities or ADL; OR
  • If both therapies are provided, the treatment programs must be separately determined and part of specific, separate written treatment plans; the therapies must provide significantly different treatments and not be seen as generally duplicating each other.
  • Enrollment in a health, athletic or similar club; OR
  • Equestrian/hippotherapy and other similar neuromuscular exercise/training programs; OR
  • Graston technique; OR
  • Group therapy sessions (as this is not one-on-one and personalized to the specificindividual’s needs); OR
  • Hands-free ultrasound; OR
  • Interactive metronome therapy; OR
  • Internal manipulation (eg, transrectal, transvaginal) for conditions including, but may not be limited to:
    • Chronic pelvic pain; OR
    • Interstitial cystitis; OR
    • Pudendal neuralgia; OR
    • Vulvodynia; OR
  • Kinesio taping; OR
  • Lactation counseling and services related to the postpartum condition when provided by or under the direction of physical therapists or occupational therapists; OR

  Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
  Revision Date: 09/12/2023
  Review Date: 06/22/2023
  Policy Number: HUM-0366-033
  Page: 20 of 41

  Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

  Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Maintenance care consists of activities that generally are intended to preserve the individual's present level of function and/or prevent regression of that level of function including, but may not be limited to the following (may be excluded in the certificate):
    • Maintenance begins when the therapeutic goals of the treatment program are achieved or when no further significant progress is made or reasonably seen as occurring; AND
    • Individual has achieved generally accepted normal levels of function and/or muscle strength and has reached a plateau (generally a period of four weeks or less, depending on the specific condition and/or individual situation); OR
  • MEDEK therapy, also known as Cuevas Medek Exercises (CME); OR
  • Myofascial release (MFR), also known as active release technique (ART); OR
  • Nonskilled services – certain types of treatment that do not generally require the skills of a qualified physical therapist or occupational therapist. Nonskilled services include, but are not limited to, (1) passive range of motion (PROM) treatment which is not specifically part of a restorative program related to a loss of function and (2) services which maintain function by using routine, repetitive and reinforced procedures after initial teaching of the individual has taken place. These also include most situations where general conditioning, recovery from an acute medical/surgical illness that caused deconditioning or increased general ability to exercise or walk are undertaken. Services that can be safely and effectively furnished by nonskilled (nonlicensed physical therapists and occupational therapists or their assistants under appropriate supervision) personnel are nonskilled services; OR
  • Orthoptics, vision training and related services (may be excluded by certificate); OR
  • Phonophoresis; OR
  • Portable (home) ultrasound devices; OR

  Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
  Revision Date: 09/12/2023
  Review Date: 06/22/2023
  Policy Number: HUM-0366-033
  Page: 21 of 41

  Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Relaxation therapy and/or massage therapy (if not delivered by a physical therapist or occupational therapist and is unrelated to a comprehensive treatment program); OR
  • Remote body and limb kinematic measurement-based therapy (eg, interactive rehabilitation exercise devices, MindMotion GO); OR
  • Sensory integration therapy; OR
  • Services and supplies for treatment of temporomandibular joint (TMJ) dysfunction and craniomandibular joint (CMJ) disorders.
  • Treatment of these disorders is generally excluded by certificate, please refer to the member's individual certificate; OR
  • Services deemed not medically necessary – It is the intent of the PT and OT coverage to have the individual receive those services that are medically necessary, who show demonstrated improvement or stabilization over a reasonable and generally predictable period of time, consistent with the condition under treatment and to achieve the stated treatment goals, consistent with the available benefits under the Plan; OR
  • Habilitative services related to activities for the general good and welfare of the individual such as exercises to promote overall fitness and flexibility, activities to provide diversion or general motivation; OR
  • Habilitative services which appear to be for the individual's and/or therapist’s convenience or to treat conditions or illnesses that are not covered under the Plan; OR
  • Therapy intended to effect improvement or restoration of function where an individual suffers a transient and easily reversible loss of function which could be reasonably expected to improve spontaneously as the individual gradually resumes normal activities; OR

  Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
  Revision Date: 09/12/2023
  Review Date: 06/22/2023
  Policy Number: HUM-0366-033
  Page: 22 of 41

  Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Treatments and/or therapies that are intended to specifically improve what are known as Instrumental Activities of Daily Living (IADL); including, but may not be limited to:
    1. Community living skills including balancing a checkbook, use of public transportation; OR
    2. Home management skills including meal preparation, laundry; OR
    3. Leisure activities including hobbies, sports or recreation of all types even if suggested as part of a PT or OT treatment plan; OR
    4. Motor vehicle driving evaluations and driving instruction. This includes automobiles, trucks, motorcycles and bicycles; OR
    5. Personal health management; OR
    6. Personal safety preparedness; OR
    7. Treatments for handwriting problems in children and/or adults; OR
  • Treatments for neurobehavioral and/or neuropsychiatric conditions provided by physical therapists and/or occupational therapists; OR
  • Treatments for sexual dysfunction; OR
  • Treatments for sports-related rehabilitation^ or other similar avocational activities including, but may not be limited to:
    1. Baseball pitching/throwing; OR
    2. Cheerleading; OR
    3. Golfing; OR
    4. Martial arts of all types; OR

  Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
  Revision Date: 09/12/2023
  Review Date: 06/22/2023
  Policy Number: HUM-0366-033
  Page: 23 of 41

  Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • at a college, high school, other school or community setting; OR
  • Personal return to running rehabilitation; OR
  • Professional and amateur tennis; OR
  • Professional and amateur/hobby/academic dance; OR
  • Weightlifting and similar activities; OR

  ^Refers to continued treatment for sports related injuries in an effort to improve above and beyond normal ability to perform ADLs; it is not intended to return the individual to their previous (or improved) level of sports competition or capability.

  • Treatments for the consequences of services/procedures/treatments that are noncovered under the Plan are also not covered; OR
  • Treatments generally known as early intervention even if not specifically called by this name, even if not formally given at a designated or otherwise credentialed or licensed early intervention center or provider

  All other indications, treatment techniques or modalities are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

  Humana members may NOT be eligible under the Plan for any of the following for ANY indications:

  • Dry hydrotherapy, also known as aqua massage, hydromassage or water massage (eg, Aqua Massage, Aqua MED, H2O Massage System and Hydrotherapy Tables); OR
  • Dry needling (needle insertion without injection); OR
  • Nonimmersive, semi-immersive or fully immersive virtual reality based therapy (eg, exergaming); OR

  Physical Therapy and Occupational Therapy Effective Date: 09/12/2023
  Revision Date: 09/12/2023
  Review Date: 06/22/2023
  Policy Number: HUM-0366-033
  Page: 24 of 41

  Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Virtual reality facilitated gait training (eg, GaitBetter)

  These are considered experimental/investigational and are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

  Background

  Additional information about musculoskeletal or neuromuscular conditions that may necessitate PT or OT may be found from the following websites:

  • National Institute of Neurological Disorders and Stroke
  • National Library of Medicine

  Medical Alternatives

  Physician consultation is advised to make an informed decision based on an individual's health needs.

  Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.