Physical medicine and rehabilitation is a medical specialty concerned with diagnosis, evaluation, and management of persons with physical impairment and disability. This specialty involves diagnosis and treatment of patients with painful or functionally limiting conditions, the management of comorbidities and co-impairments.

Pennsylvania State Mandate (Act 62 – 2008) Autism Spectrum Disorders Coverage Mandate (ASD) Effective July 1, 2009
Act 62-2008 (Autism Spectrum Disorders Coverage Mandate) requires coverage for the diagnostic assessment and treatment of autism spectrum disorders.

 Coverage is not subject to any limits on the number of visits to an autism service provider for treatment of autism spectrum disorders. Coverage is subject to copayment, deductible and coinsurance provisions, as well as any other general exclusions or limitations set forth in the member’s contract.

Coverage for physical medicine is determined according to individual or group customer benefits.

Physical medicine is considered medically necessary when ALL of the following criteria are met;

• Expectation of restoring the individual’s level or function that has been lost or reduced by injury or illness; and
• Treatment plans must be maintained in the medical record and available upon request.

Physical Medicine Evaluation
Evaluation and Management (E&M) service is considered an inherent part of a physical medicine evaluation. The E&M service is not eligible for separate payment when reported on the same day as a physical medicine evaluation.

When an Evaluation and Management service is reported in conjunction with a physical medicine evaluation the services should be combined under the appropriate code for the physical medicine evaluation.

Muscle testing, ROM testing, and physical performance testing are considered components of a physical medicine evaluation and are not eligible for separate payment when billed on the same date of service as a physical medicine evaluation.

Maintenance Therapy
Physical medicine services performed repetitively to maintain a level of function are not eligible for reimbursement unless the member has Habilitative services benefits.

A maintenance program consists of activities that preserve the individual's present level of function and prevent regression of that function. These service  would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness.

Maintenance begins when the therapeutic goals of a treatment plan have been achieved, and no additional functional progress is apparent or expected to occur. 

Habilitative Therapy
Habilitative therapy services may be considered medically necessary when the following criteria are met:

• Ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury; and/or
• Includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.

Note:

Habilitative therapy is not eligible for payment unless the member has a habilitative benefit.

*Spinal manipulation is not considered a habilitative service.

Habilitative services not meeting the criteria as outlined in this policy are considered not medically necessary.

Supervised Modalities
Supervised modalities do not require direct one-on-one contact with the individual by the provider. These are not time-based codes.

Vasopneumatic Compression 
Vasopneumatic compression is considered medically necessary for the following conditions:

• Edema of the extremities; or
• Hematoma of the leg; or
• Lymphedema of the arm; or
• Lymphedema of the leg; or
• Venous insufficiency or venous stasis disorder; or

Vasopneumatic compression not meeting the criteria as indicated in this policy is considered not medically necessary.

Vasopneumatic compression is considered a supervised modality and is not considered time-based. It should be reported only once per treatment session, regardless of the number of areas treated or the length of time required to complete treatment.

Infrared Therapy 
The use of infrared and near-infrared light and heat, including monochromatic infrared energy, when used as a physical medicine modality for the treatment of diabetic and/or non-diabetic peripheral sensory neuropathy and wounds and/or ulcers of the skin and/or subcutaneous tissues is considered not medically necassary.

Constant Attendance Modalities
Constant attendance modalities are those modalities that require direct one-on-one contact with the individual by the provider. Documentation must include the amount of time spent in providing all aspects of this service.

When two (2) constant attendance modalities are performed at the same time, using one device, the code representing the primary modality must be reported.

Aquatic Therapy
Aquatic therapy must be performed with the expectation of restoring an individuals level of function that has been lost or reduced by injury or illness. Aquatic therapy performed to maintain a level of function is considered to be a maintenance program and is not eligible for reimbursement.

A provider must have direct (one to one) contact with the individual when reporting aquatic therapy.       

Before beginning an aquatic therapy program, the provider must prepare a treatment plan that includes short-term and long-term goals that the individual can be reasonably expected to accomplish through the aquatic therapy program and the specific methods chosen.

Separate reimbursement will not be made for whirlpool or Hubbard tank in addition to aquatic therapy with therapeutic exercise for a single individual encounter.

Gait Training
Gait training may be considered medically necessary for the following indications.  

• Foot drop resulting from stroke; or
• Herniated disc(s); or
• Ankle, knee and/or hip replacement; or
• Traumatic amputations of the toe(s)

Documentation for gait training must demonstrate that the individual's gait was improved either by lengthening the gait or increasing the frequency of cadence lower-extremity. 

Gait training not meeting the criteria as indicated in this policy is considered not medically necessary. 

Vestibular Rehabilitation Therapy
A vestibular rehabilitation program typically last 45 minutes per session and is prescribed 1-2 times per week. In general, individuals remain in the program 4-8 weeks.

A vestibular rehabilitation program may be considered medically necessary for individuals with vertigo, disequilibrium, and balance deficits related to the following conditions:

• Peripheral vestibular disorders (e.g., labyrinthitis, neuritis, benign paroxysmal positional vertigo, post vestibular surgical symptoms, and bilateral vestibular loss); or
• Mixed {peripheral and central vestibular disorders; or
• Central causes of vertigo (e.g., CVA, multiple sclerosis, and mild traumatic brain injury).

A vestibular rehabilitation program not meeting the criteria as indicated in this policy is considered not medically necessary.

The following servcies are considered Experimental/Investigational and, therefore, non-covered, because the safety and effectiveness of this service cannot be established b published peer-reviewed literature. This is not an all inclusive list;

• Equestrian/Hippotherapy
• Low-Level Laser Therapy (Cold Laser Therapy)

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Physical medicine is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances including, but not limited to the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.