bmchp.org | 888-566-0008 wellsense.org | 877-957-1300 Medical Policy Physical Therapy in the Outpatient Setting Policy Number: OCA 3.54 Version Number: 14 Version Effective Date: 02/01/16 + Product Applicability All Plan Products Well Sense Health Plan Boston Medical Center HealthNet Plan New Hampshire Medicaid MassHealth NH Health Protection Program Qualified Health Plans/ConnectorCare/Employer Choice Direct Senior Care Options ◊ Notes: + Disclaimer and audit information is located at the end of this document. ◊ The guidelines included in this Plan policy are applicable to members enrolled in Senior Care Options only if there are no criteria established for the specified service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request. Review the member’s product-specific benefit documents at www.SeniorsGetMore.org to determine coverage guidelines for Senior Care Options. Policy Summary The Plan considers physical therapy (PT) for the treatment of a physical impairment to be medically necessary when Plan medical criteria are met for habilitative services and/or rehabilitative services. Plan prior authorization may be required to initiate services after the initial evaluation (but before the requested date of service for the therapy) or the prior authorization requirement may be waived; the prior authorization requirement is based on the number of visits/treatment units utilized, the type of provider rendering the physical therapy service(s), and if established medical criteria are met, as specified in the Medical Policy Statement section of this policy. Continued therapy requires prior authorization at least five (5) calendar days before the requested date of service. Physical Therapy in the Outpatient Setting (for Boston Medical Center HealthNet Plan Products) + Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan. 1 of 12 An additional Plan prior authorization is not required for physical therapy provided in an inpatient setting when the inpatient admission has been authorized by the Plan. See the BMC HealthNet Plan medical policy, Home Health Care (policy number OCA 3.719), rather than this Plan policy for prior authorization guidelines for medically necessary physical therapy provided to a member in the home setting. When prior authorization is required, it will be determined during the Plan’s prior authorization process if the service is considered medically necessary for the requested indication. See the Plan’s policy, Medically Necessary (policy number OCA 3.14), for the product-specific definitions of medically necessary treatment. Review the Medical Policy Statement section of this policy for specific prior authorization requirements and guidelines for waiving the prior authorization requirement. Description of Item or Service Physical Therapy (PT): Services that include a diagnostic evaluation and therapeutic interventions designed to improve, develop, correct, rehabilitate, or prevent the worsening of physical functions that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Medical Policy Statement The Plan considers physical therapy (PT) provided in an outpatient setting to be medically necessary for habilitative services and/or rehabilitative services when the following prior authorization guidelines (specified as item 1 below) and medical criteria (specified as item 2 below) are met and documented in the member’s medical record. Prior authorization is required after the initial evaluation, as specified below in items 1a, 1b, and 1c. See the Plan medical policy, Home Health Care (policy number OCA 3.719), rather than this Plan policy for prior authorization guidelines for medically necessary physical therapy provided to a member in the home setting. 1. Prior Authorization Guidelines: Below are the prior authorization requirements by the number of PT units utilized and the provider type rendering the service(s). a. First 32 Units (or 8 Visits) of Outpatient Physical Therapy Rendered by a Physical Therapist: The Plan does NOT require prior authorization for the first 32 units or 8 visits of outpatient PT for a provider who is certified in rendering PT services defined by scope of practice and certification. These services include a combination of PT modalities, therapeutic procedures, and/or re-evaluations performed per member per Plan year. Physical Therapy in the Outpatient Setting (for Boston Medical Center HealthNet Plan Products) + Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan. 2 of 12 b. Outpatient Physical Therapy in Excess of 32 Units Rendered by a Physical Therapist: PT services in excess of the 32 unit allowance will require Plan prior authorization and will be reviewed on an individual basis for a provider who is certified in rendering PT services defined by scope of practice and certification. These services include a combination of PT modalities, therapeutic procedures, and/or re-evaluations performed per member per Plan year. c. Outpatient Physical Therapy Rendered by Other Provider Types: Prior authorization will be required for ALL outpatient PT services when rendered by a provider who is not certified in rendering PT services defined by scope of practice and certification. 2. Medical Criteria for Physical Therapy Services: The Plan considers physical therapy medically necessary when the following criteria are met, as specified below in items a through j: a. The member presents with signs and symptoms of physical impairment relating to the neuromuscular, musculoskeletal, cardiovascular/pulmonary or integumentary systems; AND b. The request for PT service follows both of the following, as specified below in items (1) and (2): (1) An evaluation which includes the administration of diagnostic and prognostic tests to assess the member’s level of function (e.g., evaluation of range of motion, muscle strength, balance, or gait); AND (2) Design of an active corrective or restorative treatment program; AND c. The type of service requested includes ONE (1) or more of the following, as specified as item (1), (2) or (3) below: (1) Therapeutic exercise: Task-oriented activities designed, for example, to optimize aerobic capacity, aerobic endurance, functional status, balance coordination, postural stabilization, muscle strength, and/or mobilization or manipulation to restore specific loss of function or range of motion; OR (2) Functional training: Instruction on compensatory techniques to improve level of independence in activities of daily living (ADLs) such as teaching the member how to use a prosthetic device; OR Physical Therapy in the Outpatient Setting (for Boston Medical Center HealthNet Plan Products) + Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan. 3 of 12 (3) Mechanical and electrotherapeutic modalities: Superficial or deep thermal agents, mechanical methods, and/or electrical stimulation of neuromuscular, integumentary, musculoskeletal tissues to improve the response in physical functions; AND d. Habilitative services and/or rehabilitative services must meet accepted standards of PT practice, must be specific and effective treatment for the member’s diagnosis, and must be structured, systematic, goal directed, individualized and restorative in nature; AND e. The member’s condition requires treatment at a level of complexity that can only be safely and effectively performed by a licensed physical therapist or by a physical therapy assistant under the supervision of a physical therapist; AND f. The treatment program is expected to significantly improve the member’s condition within a reasonable period of time or prevent the worsening of functions that affect the activities of daily living (ADLs) that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies or injuries; AND g. PT services are provided with a written prescription by a physician in conjunction with consultation of a licensed physical therapist; AND h. For PT services beyond 20 visits per treatment episode, an updated written prescription by the treating physician must be submitted to the Plan with clinical documentation to support continued services, including the number of additional PT visits requested; AND i. The amount, frequency, and duration of PT services are reasonable according to professionally recognized standards of practice for physical therapy. The physical therapist is responsible for periodically conducting reevaluations of the member’s improvement with specific reassessment of the progress towards the treatment goals and justification for any continuation of care; AND j. Requested service meets InterQual® criteria for the member’s