Subject:
Work Hardening/Conditioning Programs
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Work hardening/conditioning is a specialized rehabilitation program that spans the transition from traditional rehabilitation therapies to return to work by simulating workplace activities and surroundings in a monitored environment. In this program, an environment is created in which returning workers can rebuild psychological self-confidence and physical reconditioning by replicating their work routine. Programs may be developed and carried out by an occupational therapist and/or physical therapist.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
Work hardening/conditioning programs are not considered medically necessary as they are for the purpose of vocational training and not for the treatment of a medical condition or injury. Thus, they are not eligible for reimbursement.
Medicare Coverage:
Per LCD L35036, Services that are related solely to specific employment opportunities, work skills or work settings (CPT codes 97545 and 97546) are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage.
For additional information, refer to Local Coverage Determination (LCD): Therapy and Rehabilitation Services (PT, OT) (L35036). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35036&ver=64&name=314*1&UpdatePeriod=711&bc=AQAAEAAAAAAAAA%3d%3d&
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Work Hardening/Conditioning Programs
References:
1. Cheng AS, Hung LK. Randomized controlled trial of workplace-based rehabilitation for work-related rotator cuff disorder. J Occup Rehabil. 2007 Sep;17(3):487-503.
2. Schaafsma F, Schonstein E, Whelan KM, et al. Physical conditioning programs for improving work outcomes in workers with back pain. Cochrane Database Syst Rev. 2010 Jan;(1):CD001822.
3. Novitas Solutions, Inc. LCD # L27513 - Physical Medicine & Rehabilitation Services, Physical Therapy and Occupational Therapy. Revision effective date: 09/01/2014. Available at: http://www.novitas-solutions.com/LCDSearchResults/faces/spaces/search/page/lcd.jspx?Jurisdiction=JL&medicareType=Part+B&_afrWindowMode=0&lcdID=L27513&_afrLoop=864323959493000&State=New+Jersey&_adf.ctrl-state=hjzd25add_4
4. Erdil M. Occupational low back pain: Treatment. In: UpToDate, Atlas SJ, Libman H, (Eds) UpToDate, Waltham, MA. (Accessed on November 13, 2017.)
5. Erdil M. Occupational low back pain: Treatment. In: UpToDate, Atlas SJ, Kunins L, (Eds) UpToDate, Waltham, MA. (Accessed on October 7, 2019.)
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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