Medical Necessity Definitions

Medical Necessity Definitions by Carriers

“Definition of Medical Necessity (Regence Blue Shield)

1. In accordance with generally accepted standards of medical practice;
2. Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

Regence King Care Gold:

Rehabilitative Services

KingCare covers medically necessary inpatient and outpatient rehabilitative care, including physical, occupational, massage, and speech therapy, designed to restore and improve a physical function lost due to a covered illness or injury. This care is considered medically necessary only if significant improvement in the lost function occurs while the care is provided and the attending physician expects significant improvement to continue. To verify whether coverage for rehabilitative services applies or continues to apply, Regence has the right to obtain written opinions from the attending physician concerning whether and to what extent the significant improvement is occurring.

Cigna HealthCare Definition of Medical Necessity for other Healthcare Providers

1. in accordance with the generally accepted standards of medical practice;
2. clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
3. not primarily for the convenience of the patient or Healthcare Provider, a Physician or any other Healthcare Provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means: standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community,

• Physician and Healthcare Provider Specialty Society recommendations,
• the views of Physicians and Healthcare Providers practicing in relevant clinical areas and
• any other relevant factors.

Premera Blue Cross Medical Necessity Policies

Physical Medicine and Rehabilitation –Physical Therapy (PM&R-PT) Physical medicine and rehabilitation physical therapy (PM&R –PT) ,including medical massage therapy services ,may be considered medically necessary when performed to meet the functional needs of a patient who suffers from physical impairment, functional limitation or disability due to disease, trauma, congenital anomalies, or prior therapeutic intervention. Physical medicine and rehabilitation –physical therapy (PM&R –PT), including medical massage therapy services may be considered medically necessary when ALL of the following criteria are met :

• The patient has a documented physical impairment, functional limitation or disability due to disease, trauma, congenital anomalies, or prior therapeutic intervention AND
• The patient has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time based on specific diagnosis-related treatment/therapy goals AND
• The service is delivered by a qualified provider of PM&R-PT Or massage therapy services AND
• Due to the physical condition of the patient, the complexity and sophistication of the therapy and the therapeutic modalities used; the judgment, knowledge, and skills of a qualified PM&R-PT or medical massage therapy provider are required.

  Physical Medicine and Rehabilitation –Physical Therapy (PM&R-PT),including medical massage therapy services are considered not medically necessary when:

• It is not part of a written plan of care for treatment of a specific diagnosis
• The services do not ordinarily require the skills, sophistication, and full attention of a qualified provider
• The patient is asymptomatic or without documented physical signs or functional symptoms of acute disability Medical Massage Therapy Medical Massage therapy may be considered medically necessary as the only Therapeutic intervention when ALL of the above criteria are met and:
• The diagnosis-specific prescription from the attending clinician with prescribing authority, stating the number of medical massage therapy visits i retained in the member’s massage therapy medical record and
• The diagnosis-specific plan of care, approved by the attending clinician with prescribing authority, is retained in the member’s massage therapy medical record Medical Massage Therapy Medical massage, also called therapeutic massage, is outcome-based massage, using specific treatment modalities targeted to the functional problem(s)or diagnosis provided by the primary licensed clinician with prescribing authority. Medical massage therapy or therapeutic massage may be provided by various qualified providers. (See Benefit Application) Massage therapists, one type of medical massage provider, are required to be licensed by most states where the service is performed .The patient must be referred to the massage therapist by a licensed clinician with prescribing authority who writes a diagnosis-specific prescription for medical massage and approves the plan of care for a specific number of therapy visits.

Premera Blue Cross definition of Maintenance Massage.

Maintenance therapy program:A maintenance therapy program consists of activities that preserve the patient’s present level of function and prevent regression of that function rather than provide immediate corrective benefit. Maintenance begins when the therapeutic goals of the Plan of Care have been achieved, or when no additional functional progress is apparent or expected to occur. This may apply to patients with chronic and stable conditions where skilled supervision is no longer required and clinical improvement is not expected. The specialized knowledge and judgment of a qualified provider may be required to establish a maintenance program; however, the continuation of PM&R-PT and/or medical massage therapy services to maintain a level of function are not covered.

Examples of maintenance therapy may include, but are not limited to:

•Additional PM&R-PT and/or medical massage therapy services when the patient’s chronic medical condition has reached maximum functional improvement

•PM&R-PT and/or massage therapy services that enhance performance beyond what is needed to accomplish routine functional tasks

•Passive stretching exercises that maintains range of motion and are performed by non-skilled personnel

https://www.premera.com/medicalpolicies/8.03.502.pdf

Aetna Medical Necessity

Massage Therapy — Massage involves manual techniques that include applying fixed or movable pressure, holding and/or causing movement of or to the body, using primarily the hands. These techniques affect the musculoskeletal, circulatory-lymphatic, nervous, and other systems of the body with the intent of improving a person’s well-being or health. The most widely used forms of massage therapy include Swedish massage, deep-tissue massage, sports massage, neuromuscular massage, and manual lymph drainage. Massage therapy is considered medically necessary as adjunctive treatment to another therapeutic procedure on the same day, which is designed to restore muscle function, reduce edema, improve joint motion, or for relief of muscle spasm. Massage therapy is not considered medically necessary for prolonged periods and should be limited to the initial or acute phase of an injury or illness (i.e., an initial 2-week period).