Medically Necessary Services

Medically necessary services are defined as covered services that an occupational therapist or other qualified healthcare providers, exercising prudent clinical judgement, would provide to a member for the purpose of evaluating or treating an illness, injury, disease or its symptoms, and that are
a. in accordance with generally accepted standards of practice
b. clinically appropriate in terms of type, frequency, extent, site and duration, and considered effective for the member’s illness, injury or disease; and
c. not primarily for the convenience of the member, therapist or other healthcare provider, and
d. not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic results as to the treatment of that member’s illness, injury or disease.

For these purposes, “generally acceptable standards of practice” means standards that are based on credible scientific evidence published in the peer-reviewed literature generally recognized by the relevant healthcare community, specialty society evidence-based guidelines or recommendation, or expert clinical consensus in the relevant clinical areas.

Coverage Criteria for Providers

Several provider specialties utilize various approaches to achieve therapeutic benefit in the treatment of neuromusculoskeletal conditions. Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) covers occupation therapy services according to our members’ benefit certificates and Horizon BCBSNJ’s medical policies. For example, occupational therapy must be provided by licensed occupational therapists (OT) or licensed occupational therapist assistants or other qualified providers. Occupational therapy services or occupational therapy modalities cannot be provided by providers not formally trained to do so. Horizon BCBSNJ does not cover a provider’s services beyond the scope of his or her license.

Definitions:

The Care Classification definitions and the Severity Classifications are used to further define medically necessary services and to support authorization determinations.

Care Classifications:

Therapeutic Care

Therapeutic care is care provided to relieve the functional loss associated with an injury or condition and is necessary to return the patient to the functioning level required to perform their activities of daily living. Therapeutic care generally occurs within a reasonable period of time and is guided by evidence-based practice of occupational therapy.

Acute Care
Acute care is care of an injury or condition characterized by short and relatively severe symptom complex, generally up to the first month following onset of injury. The condition may be induced by either traumatic or non-traumatic factors and may consist of a new condition or an exacerbation of an existing one. The need for care is proportional to the severity of the signs and symptoms of the particular case, modified by the status of healing tissues. The therapeutic goals of acute care are patient education in the recovery/healing process, reduction of symptoms and minimization of functional loss, in preparation for resolution of the injury or condition. The means and methods include a combination of direct care and a home management program to progress towards recovery of function.

Subacute Care
Subacute care is care of an injury or condition characterized by a less severe symptom complex and intermediate course. Typically, it follows an acute injury or exacerbation, and can extend up to three months from onset. Subacute care is characterized by a combination of direct care and home management consisting of exercise, symptom management, patient education, and an emphasis on compliance. The therapeutic goal of this phase is to improve functional status by increasing existing range of motion and muscle strength and reducing signs and symptoms associated with the condition or injury. Means and methods include progression of exercise, instruction in self-care, and monitoring patient compliance and motivation. Intensity of care is guided by the condition of healing tissue structures, generally including therapy visits supplemented by a home management program.

Corrective or Rehabilitative Care
Corrective or rehabilitative care is the stage of ongoing care beyond the sub-acute phase. This phase of care may last up to six months from onset. It may also refer to treatment of conditions that are chronic in nature and do not occur in conjunction with an acute or subacute phase. The therapeutic goals of this phase are reduction and management of symptoms with a goal of maximizing function over time. The means and methods include progression of exercise, continued patient education, and transition to self-management. Intensity of care is guided by functional status, focusing on home management, supplemented by therapy visits.

Supportive Care
Supportive care is that phase of care that occurs following the corrective or rehabilitative phase. The supportive care phase may last up to 12 months from onset. It may apply to chronic conditions or very severe injuries. Treatment is directed towards management of ongoing, unresolved symptoms that may or may not impact functional status. The therapeutic goal of this phase is patient/caregiver education, self-management, and prevention of deterioration of physical or functional status. The means and methods include progression of exercise and continued patient education. Intensity of care is minimal.

Palliative Care
Palliative care is typically given to alleviate symptoms and does not provide corrective benefit to the condition treated. A patient receiving palliative care, in most instances, demonstrates varying lapses between treatments. If an exacerbation of a condition occurs, care becomes therapeutic rather than palliative, and documentation of the necessity for care (e.g., etiology of exacerbation, objective findings, and desired outcomes) must be obtained.

Maintenance Care
Maintenance care may include occupational therapy that consists primarily of repetitive exercise or activity that does not result in functional improvement for the patient. Maintenance care includes regular visits in which the patient may receive palliative interventions. A maintenance status may indicate that a previous level of function may be unattainable, and there is no longer an expectation of permanent improvement in measures of pain, impairment, or disability. Maintenance care may include the management of the patient who has reached preclinical status or maximum medical improvement, where the condition is resolved or stable. Treatment is directed toward maintaining optimal body function and preventing clinical symptoms or other physical disorders.

Preventive Care Examinations (Noncovered Service)
Preventive care includes management of the asymptomatic patient. Preventive care examinations may include pre-participation athletic examination.

Condition Severity Classifications:

Severity is classified as mild, moderate and severe conditions. Severity is determined by several factors including, but not limited to, mode of onset, duration of care, loss of work days, and functional deficits.

Criteria	Mild Condition	Moderate Condition	Severe Condition
Mode of onset	Variable	Variable	Severe
Anticipated duration of care	1-6 weeks	6-10 weeks	10 or more weeks
Loss of work days	No loss of work days	0-4 days of work lost	5 or more days of work lost
Work restriction	None	Possible, depending on occupation 0-2 weeks	Restriction, depending on occupation 2 or more weeks
Functional Deficits 1. Range of motion 2. Muscle strength 3. Neurologic findings 4. BADL (Basic activities of daily living) (Bathing, dressing, feeding, transfers, bowel and bladder management, ambulation/ wheelchair mobility)	Mild/no loss Mild/no loss None Mild/no loss	Mild to moderate loss Mild to moderate loss May be present Mild to moderate	Considerable loss Considerable loss May be present Moderate to severe

For Members or Covered Persons in benefit plans that are subject to the New Jersey Autism and Developmental Disabilities mandate (effective 02/08/2010) and for ASO/ASC/Self-Insured/Self-Funded Groups which have opted to adopt the New Jersey Autism and Developmental Disabilities mandate:

[Note: For purposes of this mandate, a Developmental Disability is defined as a severe, chronic disability that:
a) is attributable to a mental or physical impairment or a combination of mental and physical impairments;
b) is manifested before the Member or Covered Person:
1. attains age 22 for purposes of the Diagnosis and Treatment of Autism and Other Developmental Disabilities provision; or
2. attains age 26 for all other provisions;
c) is likely to continue indefinitely;
d) results in substantial functional limitations in three or more of the following areas of major life activity: self-care; receptive and expressive language; learning; mobility; self-direction; capacity for independent living; economic self-sufficiency;
e) reflects the Member or Covered Person’s need for a combination and sequence of special interdisciplinary or generic care, treatment or other services which are of lifelong or of extended duration and are individually planned and coordinated.

Developmental disability includes but is not limited to severe disabilities attributable to mental retardation, autism, cerebral palsy, epilepsy, spina-bifida and other neurological impairments where the above criteria are met.]

According to the New Jersey Autism and Disabilities mandate:
• Coverage required for therapies and interventions may be subject to utilization review, including periodic review, to determine the continued medical necessity of the specified therapies and interventions.
• An updated treatment plan may only be requested once every six months from the treating physician to review medical necessity, unless Horizon BCBSNJ and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.
• Benefits for covered therapies and interventions cannot be denied on the basis that they are not restorative.]

A. Occupational therapy in the home or outpatient setting is eligible for coverage when:
1. the member has a primary diagnosis of autism or another developmental disability, and

2. the therapy is prescribed via a treatment plan which must include, but are not limited, to the following:
a. a diagnosis,
b. the proposed treatment by type, frequency, and duration,
c. the anticipated outcomes stated as goals,
d. the frequency schedule by which the treatment plan will be updated, and
e. the treating physician's signature

3. the therapy requires the judgment, knowledge and skills of a qualified provider of occupational therapy services due to the complexity and sophistication of the therapy and the physical condition of the patient. A qualified provider of occupational therapy services is one who is licensed where required and performs within the scope of licensure.

B. Continued medical necessity of occupational therapy for the treatment of autism, autism spectrum disorder, or another developmental disability will be determined upon review of progress assessment(s) and an updated treatment plan. The progress notes must indicate:
• continued functional improvement within the past treatment period as defined by the prior treatment plan, using valid and reliable instruments such as the Bayley Scales of Infant Development – II, Denver Developmental Screening Test – II, Peabody Developmental Motor Scales, Pediatric Evaluation of Disability Inventory (PEDI), WeeFIM, Patient Specific Functional Scale,
• that there is an expectation that continued therapy will result in measurable and significant improvement within a reasonable and predictable period of time based on the updated treatment plan,
• the care that is delivered is skilled, requiring the knowledge and training of a licensed clinician
• the care that is delivered is not maintenance in nature such that the caregiver or the member can perform these services independently
• the intensity of care requires the skills of the licensed clinician at the frequency the member is receiving care
• that the member and/or caregiver is actively participating in treatment sessions, and
• that generalization and carry-over of targeted skills into the natural environment is occurring.
  
C. Occupational therapy for the treatment of autism or another developmental disability cannot be denied on the basis that it is not restorative.

and
for ASO/ASC/Self-Insured/Self-Funded Groups which have opted to adopt the New Jersey Autism and Developmental Disabilities mandate who seek Occupational Therapy treatment for a diagnosis other than autism or another developmental disability
OR

Indications for Coverage:

A. Contract limitations for occupational therapy services in the home or outpatient setting will determine the available benefit if such therapy is determined to be medically necessary.

B. Occupational therapy services must be ordered by a physician.
• Each member should be provided with a treatment plan at their start of care describing appropriate treatment modalities and exercises.
• The member's treatment plan must contain the following components:
  - Diagnosis and specific dysfunction(s) to be treated.
  - Long and short term goals.
  - Measurable objectives.
  - Specific treatment techniques and/or activities to be used in the therapy.
  - The time frame and the number of visits in which the goals and objectives will be achieved.
• Re-assessments of member progress should be undertaken as part of every ongoing OT session; assessments of this nature should be included in the treatment session and should not be performed in a separate treatment session.
  - The assessment is a part of ongoing care and should occur throughout each treatment session so that therapy continues to be patient-focused to meet the changing needs of the member.
  - A formal reassessment with objective measures and updated goals should occur at least every 30 days.
  - Lack of measurable and significant change at reassessments should result in a change in the program or discharge to a home management program. Significant change is defined as a clinically meaningful increase (as documented in the member's record) in the member’s level of physical and functional abilities that can be attained with short-term therapy, usually within a two month period.

C. Occupational therapy services are reviewed and evaluated by Horizon BCBSNJ or delegated entity periodically during a member’s episode of care.
• At each review, Horizon BCBSNJ will generally evaluate the key objective and subjective measures of the member’s clinical status, including function.
• This information, in the context of the generally accepted natural history of the condition(s) under care, will be used to determine the medical necessity of the care provided to date, and/or the care that is proposed.

D. Occupational therapy in the home setting requires the member to meet homebound criteria. An individual shall be considered "confined to home" (homebound) when both criteria are met:
1. The member must either:
• because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence; or
• have a condition such that leaving his or her home is medically contraindicated.

And

2. There must exist a normal inability to leave home and leaving home must require a considerable and taxing effort.

Medically Necessary Services

Occupational therapy (OT) services designed to improve function are considered medically necessary for treatment of illness or injury only when the expectation exists that the result of the therapy will result in improvements of daily living skills within a reasonable period of time. The following are important components of skilled therapy services:

1. Therapy requires the judgement, knowledge, and skills of a qualified provider of occupational therapy services due to the complexity and sophistication of the therapy and the physical condition of the member.
- A qualified provider of occupational therapy services is one who is licensed where required and performs within the scope of his/her licensure.

2. OT services meet the functional needs of the member who suffers from physical impairment due to illness, disease, injury or therapeutic intervention;
- The member must have functional deficits that interfere with activities of daily living (ADLs);

3. OT services achieve a specific diagnosis-related goal for a member, who has a reasonable expectation of achieving measurable improvement, in a reasonable and predictable period of time;

4. OT services provide specific, effective, and reasonable treatment for the member's diagnosis and physical condition;

5. OT services are for the restoration of basic functional activities of daily living.

6. OT services must be described in the member's medical records using standard and generally accepted medical/occupational therapy/rehabilitation terminology. Such terminology includes objective measurements for ranges of motion, motor ability, and levels of function.
• Standardized tests for strength, motion, and function are required. Examples of validated tests include the Oswestry, DASH, TUG, Functional Status Scale, etc.
• Standardized subjective measurements for pain are also expected;

7. OT services inherently include the introduction and provision of, and education about a home (self) management program, appropriate for the condition(s) under treatment. In keeping with professional standards, this home management program should be introduced into the course of treatment at the earliest appropriate time; (Education about a home (self) management program may include, as applicable, parents, guardians, and/or other caregivers of pediatric patients and family caregivers for adult patients.)

8. OT treatment must include active, skilled therapy (i.e., that requiring an occupational therapist or physician) during each session, at an intensity and of a duration necessary to the condition(s) under treatment. The number of visits should not exceed the intensity of the treatment plan required to treat the member's condition.
Occupational Therapy (OT) Services NOT Considered Medically Necessary Include the Following:

• OT services provided for the return to sport or recreational activities (e.g., golf, tennis, running, jogging, swimming, basketball, gymnastics, football, baseball, martial arts, dance, etc.), or for the performance of work-related or other specific vocational tasks.
• OT services for general physical conditioning
• OT services in connection with self-help devices
• Maintenance OT services
  • Maintenance is the point at which no further improvement in restoration of function, reduction in disability, or relief of pain is demonstrated or expected.
  • Continuation of therapy at this point would be for the purpose of holding at a steady state or preventing deterioration.
  • Coverage is not available for therapy which is intended to maintain the patient’s status and prevent deterioration but which is not expected to significantly improve the condition.
  • Also excluded is therapy to improve overall fitness, endurance, distance or motivation or to assist with weight loss programs.
• Palliative OT services
  - Palliative care, also known as comfort care or symptom management, is typically given to alleviate symptoms and does not provide corrective benefit to the condition treated.
• OT services for preventive care for management of the asymptomatic patient.
  - Preventive care refers to measures taken to prevent diseases (or injuries) rather than curing them or treating their symptoms.
  - Preventive care examinations may include pre-vocational or ergonomic assessments.
• Ongoing or prolonged treatment for chronic conditions and/or chronic pain in the absence of measurable improvement that is sustained from treatment visit to treatment visit or when the condition is not expected to improve significantly within a reasonable time period
  - Therapy is not meant to address ongoing safety issues related to cognitive and physical impairments that do not appear to be improving.
• Non- skilled therapy including, but is not limited to, routine, repetitive and reinforced procedures that do not require one-to-one intervention such as using a UBE, progressive resistive exercise after instruction, and passive range of motion. These procedures do not generally require the skills of a qualified provider of OT services. Care that does not change from visit to visit and/or that can be done independently by the member or a caregiver at home after instruction is not considered skilled.
• Occupational therapy services provided by OT aides, massage therapists, athletic trainers, exercise physiologists, or other non-qualified professionals not recognized by Horizon BCBSNJ.
• Duplicate therapy, i,e., treatment by two therapists of the same discipline employed by two different providers for the same problem (e.g., two occupational therapists treating the same patient for an upper extremity injury.) When a patient receives both occupational and physical or speech therapy, the therapies should provide different interventions and not duplicate the same treatment. They must have separate treatment plans and goals with treatment occurring in separate treatment sessions and visits.
• Specific modalities such as infrared (97026) including Anodyne, and laser therapy (97039) [Refer to separate medical policies on Low-Level Laser Therapy (#074) and Infrared Therapy (#068) in the Treatment Section of this database.]
• Work hardening, community work integration programs and functional capacity evaluations (CPT 97545, 97546, 97537) (Refer to a separate medical policy on Work Hardening/Conditioning Programs (Policy # 012) in the Allied Section of this database)
• When a member's improvement potential is insignificant when compared to the extent and duration of the therapy needed.
• When the member suffers a temporary loss or reduction of function and could reasonably be expected to improve spontaneously without the services of an occupational therapist.

Clinical Discharge Criteria

Criteria utilized for determining whether a member is eligible for discharge from OT is determined on the following (objective data):

1. Functional range of motion (ROM) for the injured or impaired body part(s). ROM measurements will be reviewed on an individual basis.

• ROM measurements will be reviewed on an individual basis.
• ROM values will be compared to standard normative measures that have been published in the medical/orthopedic literature with respect to functional ability as demonstrated by the member

2. Satisfactory motor ability of the impaired or injured part(s) such that further improvement can be accomplished with a home exercise (management) program (HEP).

3. The member is able to perform activities of daily living (ADLs) such as walking in the home, bathing, grooming, feeding, positioning, dressing and elimination.

4. For additional therapy requests to be considered medically necessary, they must include documented objective, measurable clinical data demonstrating the need for continued treatment.
• Valid and reliable instruments should be used to provide the data.
• In those instances when no documented continual progression of function or improvement over the course of treatment, or a negative trend occurs, further OT services generally will not be approved due to lack of medical necessity.

5. If the member has been non-compliant with therapy as evidenced by the clinical documentation, and/or clinical documentation indicates the lack of demonstrated progress, OT will be deemed to not be medically necessary and the member should be discharged from OT.

6. Occupational therapy services are not considered medically necessary for pain mediation alone. The goals of OT are for improvement in restoration of function, motor ability, and range of motion as indicated previously.

97014
97016
97018
97022
97032
97034 - 97035
97110
97112 - 97113
97124
97140
97530
97535
97542
97760 - 97761