Oscar Home Care - Physical Therapy/Occupational Therapy (CG021) Form

Skilled Home Care Rehabilitation Services

Members recently discharged from the hospital and/or those diagnosed with certain medical conditions may require short-term skilled care in the home for rehabilitation. When medically necessary, such services can be used to restore or improve functional independence. Physical therapy (PT) and occupational therapy (OT) are examples of these skilled home care services.

Physical Therapy (PT)

PT is designed to improve functioning, relieve disease symptoms, and prevent disability in individuals with acute and chronic disease. Treatments may consist of heat and cold therapy, electric stimulation, a variety of exercise regimens, and functional training for ambulatory activities. PT may be performed by a qualified, licensed physical therapist or by a physical therapy assistant (PTA) under the supervision of a qualified, licensed physical therapist.

Occupational Therapy (OT)

OT is designed to provide individuals with purposeful activities and training to regain skills of daily living that were lost through disease or injury. OT may be performed by a qualified, licensed occupational therapist or by an occupational therapy 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. Home PT and OT require a prescription and clear documentation of progress,¹goals, and ongoing necessity. Home PT and OT should also include a home exercise and activity program designed for the member to participate in alone or with the help of caregivers that do not require skilled personnel present.

This guideline provides criteria regarding the indications and exclusions for PT and OT.

Information about coverage and benefit limitations can be found in the member’s plan contract at hioscar.com/forms.

Definitions

"Homebound"

"Homebound" refers to members who have normal inability to leave home without considerable and taxing effort (i.e., requires an assistive device or the assistance of another person to leave home) AND one of the following:

• Members who cannot leave home due to a medical condition, chronic disease, or injury; or
• Members advised by a treating provider not to leave home for various reasons (e.g. safety, ongoing medical treatment needs, etc); or
• Members who need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, special transportation (when the member is unable to use common transportation such as private automobile, bus, taxi due to medical condition), or the assistance of others to leave their place of residence.

When the member does leave home, the absence of the member from the home is infrequent or for short periods of time, such as to receive health treatment or adult daycare (non-residential program providing services during the day).

"Physical Therapy (PT)" and "Occupational Therapy (OT)"

"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:

1. Ambulation and mobility training
2. Gait and balance training
3. Strength training
4. Joint mobilization
5. Neuromuscular reeducation
6. Therapeutic exercises
7. Assistive device and adaptive equipment training
8. Orthotic or prosthetic training
9. Transfer training

"Occupational Therapy" 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 that2have 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:

1. Activities of Daily Living (ADL) training
2. Muscle re-education
3. Cognitive or neurodevelopmental training
4. Perceptual motor training
5. Fine motor coordination/strength training
6. Assistive device and adaptive equipment training
7. Environment modification recommendations and training
8. Transfer training
9. Functional mobility training
10. Manual therapy

"Activities of Daily Living (ADLs)" and "Instrumental Activities of Daily Living (IADLs)"

"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, dressing, feeding, grooming, mobility, 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 public transportation, balancing a checkbook, community living activities, meal preparation, laundry, leisure activities and sports, and motor vehicle operation.

"Rehabilitative Treatments" and "Habilitative Treatments"

"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 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. This is different from rehabilitative treatment in that habilitative treatments are for individuals that have not developed to the expected level of function or have not yet met a development milestone; an example includes therapy for a child who is not talking at the expected age.

"Custodial Care" and "Long-term Care"

"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.³

Hospice Care / End-of-Life Care

Hospice Care / End-of-Life Care - are interdisciplinary and holistic care when curative or life-prolonging treatments are no longer beneficial and services may focus on symptom control, psychosocial and spiritual care, nursing, or short-term acute services. Trained clinicians and support staff support individual and family quality-of-life goals. Hospice care can be provided in the home, skilled nursing facility, or hospital setting (for acute symptom management and stabilization to return to previous level of hospice care).

Palliative Care

Palliative Care - are interdisciplinary and holistic care that focuses on symptom management, relieving suffering in all stages of disease, supporting communication, assessing psychosocial and spiritual resources, social and economic resources. Members may receive curative or life-prolonging treatment, and may not choose to receive hospice care or end-of-life care. Furthermore, palliative care provides support for individual and family quality-of-life goals.

Clinical Indications

Physical Therapy and Occupational Therapy in the home is medically necessary 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, NP, or PA) as per individual state law and must be provided by a licensed physical or occupational therapist; and
2. The member meets the definition of homebound (see Definitions section above); and
3. Medical necessity criteria in the appropriate MCG Home Care Optimal Recovery Guidelines or MCG Home Care General Recovery Guideline are met; and/or
4. For members requesting hospice care/end-of-life care or palliative care (please check plan benefits to verify hospice or palliative care benefit timeframes), the following criteria must be met to meet medical necessity:
   • The member is terminally ill, presenting with functional decline, and certified by a medical practitioner for life expectancy less than twelve months for palliative care and less than six months for hospice/end-of-life care; and
   • The PT/OT services are rendered as part of a hospice care program; and
   • The member may receive curative treatment while receiving palliative care; and/or
   • The member is not receiving curative treatment while in hospice care; and
5. Therapy is aimed at establishing or restoring function that was lost or impaired as a result of disease, injury, or procedure; and
6. 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
7. Improvement can be expected with sustainable benefit in range of motion, strength, function, reduced pain level, and independence of ADLs; and
8. The written plan of care includes an initial evaluation and is sufficient to determine the necessity of therapy, including the following elements:
   • A medical evaluation has been conducted within 30 days of the service dates; and
   • 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 level of functioning and current level of functioning; 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;
   • The specific treatment techniques and/or exercises to be used; and
   • Discharge plan.

Documentation of medical necessity should be reviewed when ANY of the following occur:

1. The plan of care exceeds the expected duration and/or estimated frequency of care; or
2. There is a change in the member’s condition that may impact the plan of care; or
3. The specific goals are no longer expected to be achieved in a reasonable or expected duration of time.

DurationofTherapy

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

ExtensionRequests

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

1. A re-evaluation has been conducted within 30 days of the service dates; and
   • The appropriate MCG Home Care Optimal Recovery Guidelines with the Extended Visits criteria are met; or
   • The appropriate MCG Home Care General Recovery Guideline and the member is still in General Treatment Course Stage 2 or has not met all of the milestones in Stage 3;
2. For an extension request/recertification for hospice or palliative care, please see plan benefits and requirements.

Experimental or Investigational / Not Medically Necessary

Skilled care, and thus physical and occupational therapy, should be discontinued when one of the following is present:

• Homebound status is no longer met; or
• 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
• 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
• Chronic illness / chronic flare-ups or exacerbations that did not result in a decline in function or related to an acute exacerbation; 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 care or Long-term care services; or
• Duplicative therapy services or programs; or
• Treatment modalities or home exercises that do not require a licensed PT/OT and can safely be conducted by the member alone or with the help of family or caregivers; or
• Therapy aimed at improving or restoring only IADLs; or
• Occupational or recreational programs aiming to augment or improve upon normal human functioning; this includes services considered as routine, conditioning, educational, for employment or job training, or as part of a fitness or sports program; or
• Pilates or general exercises to promote fitness or flexibility are not medically necessary; or
• Transcutaneous electrical nerve stimulator (TENS) in the home setting is not medically necessary, please refer to the Plan Clinical Guideline: Outpatient Physical Therapy & Occupational Therapy (CG044) for outpatient setting; or
• Neuromuscular electrical stimulation (NMES) / Electrical Muscle Stimulation in the home setting is not medically necessary, please refer to Plan Clinical Guideline: Outpatient Physical Therapy & Occupational Therapy (CG044) for outpatient setting; or
• 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:

• Augmented soft tissue mobilization is considered investigational due to limited evidence of improved outcomes over standard techniques for soft tissue mobilization
• Cognitive skills training to improve memory or problem solving
• Driver/safety training
• Equestrian therapy (hippotherapy)
• Group therapy (criteria require individualized plans)
• Kinesio taping for back pain or radicular pain is considered investigational and not clearly established in the literature
• Low level laser therapy (LLLT)
• MEDEK Therapy (Metodo Dinamico de Estimulacion Kinesica or Dynamic Method for Kinetic Stimulation)
• Microcurrent electrical nerve stimulation (MENS)
• Interferential stimulation or interferential current therapy (IF) 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.
• The Interactive Metronome Program
• Sensory integrative techniques
• Vertebral axial decompression and motorized traction devices

Conditions 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:

• Constipation
• Vaginismus
• Social functioning
• Sexual dysfunction (erectile dysfunction, premature ejaculation)
• Scoliosis
• TMJ pain