RETIRED Local Coverage Determination (LCD)

Therapy and Rehabilitation Services

L33413

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.
Retired

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33413
Original ICD-9 LCD ID
Not Applicable
LCD Title
Therapy and Rehabilitation Services
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/01/2019
Revision Ending Date
03/01/2023
Retirement Date
03/01/2023
Notice Period Start Date
N/A
Notice Period End Date
N/A
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Current Dental Terminology © 2023 American Dental Association. All rights reserved.

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Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Therapy and Rehabilitation Services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Therapy and Rehabilitation Services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site.

Internet Only Manual (IOM) Citations:

  • CMS IOM Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual,
    • Chapter 4 Physician Certification and Recertification of Services
  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
    • Chapter 7 Home Health Services
    • Chapter 12 Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage
    • Chapter 15, Section 220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance and Section 230 Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
  • CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,
    • Chapter 1, Part 2, Section 150.8 Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders, Section 160.12 Neuromuscular Electrical Stimulator (NMES), 160.15 Electrotherapy for Treatment of Facial Nerve Palsy (Bell’s Palsy), Section 160.2 Treatment of Motor Function Disorders with Electric Nerve Stimulation
    • Chapter 1, Part 4, Section 230.8 Non-Implantable Pelvic Floor Electrical Stimulator and Section 270 Wound Treatment, Section 270.1 Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds – (Effective July 1, 2004), Section 270.2 Noncontact Normothermic Wound Therapy (NNWT), Section 270.3 Blood-Derived Products for Chronic Non-Healing Wounds - (Various Effective Dates Below), Section 270.4 Treatment of Decubitus Ulcers, Section 270.5 Porcine Skin and Gradient Pressure Dressings, Section 270.6 Infrared Therapy Devices (Effective October 24, 2006)
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 5 Part B Outpatient Rehabilitation and CORF/OPT Services
    • Chapter 12, Section 30.3 D. Aural Rehabilitation Services
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual,
    • Chapter 3, Section 3.3.2.7 Review Guidelines for Therapy Services
    • Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

National Correct Coding Initiative (NCCI) Citation:

  • NCCI Policy Manual for Medicare Services
    • Chapter 11, Section H. Otorhinolaryngologic Services, Subsection 2., 3., and 4.

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury. 
  • Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations. 
  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Federal Register References:

  • Code of Federal Regulations (CFR), Title 42, Volume 2, Chapter IV, Part 410.61 Plan of treatment requirements for outpatient rehabilitation services and Part 410.105 Requirements for coverage of CORF services.
  • Code of Federal Regulations (CFR), Title 42, Volume 3, Chapter IV, Part 424.24 Requirements for medical and other health services furnished by providers under Medicare Part B

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Please refer to the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220 for definitions, references, general therapy guidelines, furnishing therapy services in a pool, conditions of coverage and payment, care of a physician/nonphysician practitioner, plan of care requirements, certification and recertification of need for treatment and therapy plans of care, requirement that services be furnished on an outpatient basis, covered indications and limitations, documentation requirements, functional reporting.

Please refer to the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230 for regulations regarding the practice of physical therapy, occupational therapy, and speech-language pathology.

Please refer to the CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, Section 150.8 Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders for covered indications and limitations, Section 160.15 Electrotherapy for Treatment of Facial Nerve Palsy (Bell’s Palsy) regarding limitations, and Section 160.2 Treatment of Motor Function Disorders with Electric Nerve Stimulation regarding limitations.

Please refer to the CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 230.8 Non-Implantable Pelvic Floor Electrical Stimulator for covered indications and limitations and Section 270.6 Infrared Therapy Devices (Effective October 24, 2006) for limitations.

Covered Indications

Specific Procedure and Modality Guidelines for Physical and/or Occupational Therapy

Evaluation for physical therapy and for occupational therapy

The initial evaluation identifies the problem or difficulty the patient is having which helps determine the appropriate therapy necessary to treat the patient. An evaluation is a comprehensive service requiring professional skills to make clinical judgments about conditions for which services are indicated. If a new diagnosis/problem is encountered, then an additional evaluation may be appropriate to determine what course of treatment is necessary for the separate identifiable diagnosis/problem.

Re-evaluations are indicated periodically when the professional assessment indicates a significant improvement or decline in the patient's condition or functional status. The re-evaluation focuses on the patient's progress toward current goals. Professional judgment is used to determine continued care, modifying goals and/or treatment or terminating services.

Traction/Mechanical Modality

Traction is generally used for joints, especially of the lumbar or cervical spine, with the expectation of relieving pain in or originating from those areas, or increasing the range of motion of the joint. Specific indications for the use of mechanical traction include, but are not limited to, neck and back disorders such as disc herniation, lumbago, cervicalgia, sciatica, cervical and lumbar radiculopathy. This modality is generally used in conjunction with therapeutic procedures and not as an isolated treatment.

Vasopneumatic Devices

The use of vasopneumatic devices may be considered medically necessary for the application of pressure to an extremity for the purpose of reducing edema. 

Specific indications for the use of vasopneumatic devices include:

  • reduction of edema after acute injury;
  • lymphedema of an extremity; and/or
  • education on the use of a lymphedema pump for home use.

Paraffin Bath

Paraffin bath, also known as hot wax treatment, is primarily used for pain relief in chronic joint problems of the wrists, hands, and feet.

Specific indications for the use of paraffin baths include:

  • the patient has a contracture as a result of rheumatoid arthritis;
  • the patient has a contracture as a result of scleroderma;
  • the patient has acute synovitis;
  • the patient has post-traumatic conditions;
  • the patient has hypertrophic scarring;
  • the patient has degenerative joint disease;
  • the patient has osteoarthritis;
  • the patient has post-surgical conditions or tendon repairs, or
  • the patient is status post sprains or strains.

Whirlpool /Hubbard Tank

Whirlpool bath and Hubbard tanks are the most common forms of hydrotherapy. The use of sterile whirlpool is considered medically necessary when used as part of a plan directed at facilitating the healing of an open wound (e.g., burns).

Specific indications for the use of sterile whirlpools include:

  • the patient has a documented open wound which is draining, has a foul odor, or evidence of necrotic tissue; and/or
  • the patient has a documented need for wound debridement/bandage removal.

General whirlpool therapies/Hubbard tank are considered medically necessary when used to enhance the patient's ability to perform therapeutic exercise.

Specific indications for the use of general whirlpool therapies include:

  • the patient who suffers from generalized weakness in addition to a specific functional limitation, and requires the buoyancy provided in the whirlpool in order to perform the therapeutic exercise, and/or
  • the patient who requires joint stretching (joint range of motion) prior to exercise on dry land.

General whirlpool therapies/Hubbard tank may be considered medically necessary when the patient's condition is complicated by either circulatory deficiency or areas of desensitization, and the therapeutic goal is to increase circulation or decrease skin sensitivity.

Diathermy

Short wave diathermy is an effective modality for heating skeletal muscle. Because heating is accomplished without physical contact between the modality and the skin, it can be used even if skin is abraded, as long as there is no significant edema. The use of diathermy is considered medically necessary for the delivery of heat to deep tissues such as skeletal muscle and joints for the reduction of pain, joint stiffness, and muscle spasms.

Specific indications for the use of diathermy include:

  • the patient has osteoarthritis, rheumatoid arthritis, or traumatic arthritis;
  • the patient has sustained a strain or sprain;
  • the patient has acute or chronic bursitis;
  • the patient has sustained a traumatic injury to muscle, ligament, or tendon resulting in functional loss;
  • the patient has a joint dislocation or subluxation;
  • the patient requires treatment for a post surgical functional loss;
  • the patient has an adhesive capsulitis; and/or
  • the patient has a joint contracture.

Ultraviolet Therapy

Photons in the ultraviolet (UV) spectrum are more energetic than those in the visible or infrared regions. Their interaction with tissue and bacteria can produce nonthermal photochemical reactions, the effects of which provide the rationale for ultraviolet treatment. Ultraviolet light is highly bacteriocidal to motile bacteria, and it increases vascularization at the margins of the wounds.

The application of ultraviolet therapy is considered medically necessary for the patient requiring the application of a drying heat. The specific indications for this therapy are:

  • A patient having an open wound. Minimal erythema dosage must be documented.
  • Severe psoriasis limiting range of motion.

Electrical Stimulation (Manual)

This modality includes the following types of electrical stimulation:

  • Transcutaneous electrical nerve stimulation which produces analgesia, strengthening, and functional electrical stimulation. The use of electrical stimulation is considered medically necessary to reduce pain and/or edema and achieve muscular contraction during exercise.
  • High voltage pulsed current, also called electrogalvanic stimulation, which may be useful for the reduction of swelling and the control of pain.
  • Neuro-muscular stimulation which is used for retraining weak muscles following surgery or injury and is taken to the point of visible muscle contraction.
  • Interferential current/medium current units, which use a frequency that allows the current to go deeper. IFC is used to control swelling and pain.

Specific indications for the use of electrical stimulation include:

  • the patient has documented dependent peripheral edema with an accompanying reduction in the ability to contract muscles;
  • the patient has a documented reduction in the ability to contract muscles or in the strength of the muscle contraction;
  • the patient has a condition that requires an educational program for self-stimulation of denervated muscle (educational program should be limited to 5-7 sessions);
  • the patient has a condition that requires muscle re-education involving a training program (e.g., functional electrical stimulation);
  • the patient has a painful condition that requires analgesia or a muscle spasm that requires reduction prior to an exercise program; or
  • the patient is undergoing treatment for disuse atrophy using a specific type of neurostimulator (NMES) which transmits an electrical impulse to the skin over selected muscle groups by way of electrodes. Note: Coverage for this indication is limited to those patients where the nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves, and other non-neurological reasons for disuse are causing the atrophy (e.g., post casting or splinting of a limb, and contracture due to soft tissue scarring).

Iontophoresis Application

Iontophoresis is a process in which electrically charged molecules or atoms (e.g., ions) are driven into tissue with an electric field. Voltage provides the driving force. Parameters such as drug polarity and electrophoretic mobility must be known in order to be able to assess whether iontophoresis can deliver therapeutic concentrations of a medication at sites in or below the skin.

The application of iontophoresis is considered medically necessary for the topical delivery of medications into a specific area of the body. The medication and dosage information may be recorded in the plan of treatment or maintained on a separate prescription signed by the health care provider responsible for certifying the plan of treatment.

Specific indications for the use of iontophoresis application include:

  • the patient has tendonitis or calcific tendonitis;
  • the patient has bursitis; or
  • the patient has adhesive capsulitis.

Contrast Baths

Contrast baths are a special form of therapeutic heat and cold that can be applied to distal extremities. The effectiveness of contrast baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold. Although a variety of applications are possible, contrast baths often are used in treatment programs for rheumatoid arthritis and reflex sympathetic dystrophy.

The use of contrast baths is considered medically necessary to desensitize patients to pain by reflex hyperemia produced by the alternating exposure to heat and cold.

Specific indications for the use of contrast baths include:

  • the patient has rheumatoid arthritis or other inflammatory arthritis;
  • the patient has reflex sympathetic dystrophy; or
  • the patient has a sprain or strain resulting from an acute injury.

Ultrasound Application

Therapeutic ultrasound is a deep heating modality that produces a sound wave of 0.8 to 3.0 Mhz. In the human body ultrasound has several pronounced effects on biologic tissues. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone can receive an even greater dosage of ultrasound, as much as 30% more. Because of the increased extensibility ultrasound produces in tissues of high collagen content, combined with the close proximity of joint capsules, tendons, and ligaments to cortical bone where they receive a more intense irradiation, it is an ideal modality for increasing mobility in those tissues with restricted range of motion.

The application of ultrasound is considered medically necessary for patients requiring deep heat to a specific area for reduction of pain, spasm, and joint stiffness, and the increase of muscle, tendon and ligament flexibility.

Specific indications for the use of Ultrasound Application include:

  • the patient has tightened structures limiting joint motion that require an increase in extensibility; or
  • the patient has symptomatic soft tissue calcification.

Therapeutic Exercise

Therapeutic exercise is performed on dry land with a patient either actively, active-assisted, or passively participating (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening).

Therapeutic exercise is considered medically necessary if at least one of the following conditions is present and documented:

  • the patient having weakness, contracture, stiffness secondary to spasm, spasticity, decreased range of motion, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance, or
  • the patient needing to improve mobility, stretching, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance as part of activities of daily living training, or re-education.

Neuromuscular Reeducation

This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation, Feldenkreis, Bobath, BAP's boards, and desensitization techniques).

Neuromuscular reeducation may be considered medically necessary if at least one of the following conditions is present and documented:

  • the patient has the loss of deep tendon reflexes and vibration sense accompanied by paresthesia, burning, or diffuse pain of the feet, lower legs, and/or fingers;
  • the patient has nerve palsy, such as peroneal nerve injury causing foot drop; or
  • the patient has muscular weakness or flaccidity as a result of a cerebral dysfunction, a nerve injury or disease, or having had a spinal cord disease or trauma.

Aquatic Therapy with Therapeutic Exercise

This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). Hydrotherapy is useful in post- operative extremity (joint) rehabilitation (e.g., total hip or knee arthroplasty, total shoulder, elbow, wrist arthroplasty).

Aquatic therapy with therapeutic exercise may be considered medically necessary if at least one of the following conditions is present and documented:

  • the patient has rheumatoid arthritis;
  • the patient has had a cast removed and requiring mobilization of limbs;
  • the patient has paraparesis or hemiparesis;
  • the patient has had a recent amputation;
  • the patient is recovering from a paralytic condition;
  • the patient requires limb mobilization after a head trauma; or
  • the patient is unable to tolerate exercise for rehabilitation under gravity based weight bearing.

Gait Training

This procedure may be medically necessary for training patients whose walking abilities have been impaired by neurological, muscular, or skeletal abnormalities or trauma.

Specific indications for gait training include:

  • the patient has suffered a cerebral vascular accident resulting in impairment in the ability to ambulate, now stabilized and ready to begin rehabilitation;
  • the patient has recently suffered a musculoskeletal trauma, either due to an accident or surgery, requiring ambulation education;
  • the patient has a chronic, progressively debilitating condition for which safe ambulation has recently become a concern;
  • the patient has had an injury or condition that requires instruction in the use of a walker, crutches, or cane;
  • the patient has been fitted with a brace prosthesis and requiring instruction in ambulation; and/or
  • the patient has a condition that requires retraining in stairs/steps or chair transfer in addition to general ambulation.

Please refer to the CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, Section 160.12 Neuromuscular Electrical Stimulator (NMES) for covered indications and limitations for the treatment of muscle atrophy and for use for walking in patients with spinal cord injury (SCI).

Therapeutic Massage Therapy

Massage is the application of systemic manipulation to the soft tissues of the body for therapeutic purposes. Although various assistive devices and electrical equipment are available for the purpose of delivering massage, use of the hands is considered the most effective method of application, because palpation can be used as an assessment as well as a treatment tool.

Massage therapy, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) may be considered medically necessary if at least one of the following conditions is present and documented:

  • the patient has paralyzed musculature contributing to impaired circulation;
  • the patient has excessive fluids in interstitial spaces or joints;
  • the patient has sensitivity of tissues to pressure;
  • the patient has tight muscles resulting in shortening and/or spasticity of affective muscles;
  • the patient has abnormal adherence of tissue to surrounding tissue;
  • the patient requires relaxation in preparation for neuromuscular re-education or therapeutic exercise; or
  • the patient has contractures and decreased range of motion.

Manual Therapy

Manual therapy includes the following modalities:

  • Manual traction may be considered reasonable and necessary for cervical radiculopathy.
  • Joint mobilization (peripheral or spinal) may be considered reasonable and necessary if restricted joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.
  • Myofascial release/soft tissue mobilization, one or more regions, may be medically necessary for treatment of restricted motion of soft tissues in involved extremities, neck, and trunk. Skilled manual techniques (active or passive) are applied to soft tissue to effect changes in the soft tissues, articular structures, neural or vascular systems. Examples are facilitation of fluid exchange, or stretching of shortened muscular or connective tissue. This procedure may be medically necessary as an adjunct to other therapeutic procedures such as therapeutic exercises, neuromuscular reeducation, and therapeutic activities.
  • Manipulation may be medically necessary for treatment of painful spasm or restricted motion of soft tissues. It may also be used as an adjunct to other therapeutic procedures such as therapeutic exercises, neuromuscular reeducation, and therapeutic activities.

Therapeutic Activities

Therapeutic activities are considered medically necessary for patients needing a broad range of rehabilitative techniques that involve movement. Movement activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching, and overhead activities) to improve functional performance in a progressive manner. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the professional skills of a therapist and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active treatment plan and be directed at a specific outcome.

In order for therapeutic activities to be covered, the following requirements must be met:

  • the patient's condition is such that he/she is unable to perform therapeutic activities except under the direct supervision of a physician or physical therapist; and
  • there is a clear correlation between the type of exercise performed and the patient s underlying medical condition for which the therapeutic activities were prescribed.

Other Therapeutic Procedures – Development of Cognitive Skills and Sensory Integrative Techniques

Development of cognitive skills to improve attention, memory or problem solving, may be medically necessary for patients having neurologic conditions such as head injury or trauma, stroke, muscular dystrophy and/or multiple sclerosis or other neurological diseases. Reassessment of the patient's progress should occur every 2-3 months showing significant and measurable improvement. These procedures may be medically necessary when included in a patient's individual treatment plan aimed at improving or restoring specific functions which were impaired by an identified illness or injury and when the improved functional physical/cognitive abilities of the patient that are expected to be achieved are specified in the plan. If at any time during the treatment period it becomes obvious that continued cognitive rehabilitation is not likely to be effective, that the service is no longer needed, or that all realistic attainable goals have been met then the treatment should be discontinued. The patient must have the capacity to learn from instructions.

Self-Care/Home Management Training  

This procedure is medically necessary only when it requires the professional skills of a therapist, is designed to address specific needs of the patient, and is part of an active treatment plan directed at a specific outcome.

The patient must have the capacity to learn from instructions.

Services provided concurrently by physicians, optometrists, physical therapists, and occupational therapists may be covered if separate and distinct goals are documented in the treatment plans.

Wheelchair Management (e.g., assessment, fitting, training)

An assessment may be done to evaluate the patient's need for a wheelchair. This may include the patient's strength, living situation, weight, skin integrity, etc. Once the patient's needs are established, measurements are taken prior to ordering the equipment.

For assessment and fitting, the patient's abilities are observed, maneuverability skills are practiced and instructions are provided for adjustments to the wheelchair and wheelchair use.

Usually, the assessment(s) and fitting can be completed in 1-2 sessions. Medical necessity must support additional sessions.

Wheelchair management also trains the patient in functional activities that promote optimal safety, mobility and transfers. Patients who are wheelchair bound may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications.

This procedure is medically necessary only when it requires the professional skills of a therapist, is designed to address specific needs of the patient, and may be part of an active treatment plan directed at a specific goal.

The patient must have the capacity to learn from instructions.

Physical Performance Test or Measurement

A physical performance test or measurement may be reasonable and necessary for patients with neurological or musculoskeletal conditions when there is a need to evaluate the ability to perform specific tasks. It may include a number of multi-varied tests and measurements of physical performance of a select area or number of areas. These services are not to be used in lieu of evaluation or re-evaluation services. It is not medically reasonable and necessary to bill this service as part of a routine assessment/evaluation of rehabilitation services. Direct one-on-one patient contact is required.

Assistive Technology Assessment

This procedure is used by the provider to assess for the suitability and benefits of technological interface that will help restore, augment, or compensate for existing functional ability in the patient.

The patient's voluntary motions (e.g., oral motor strength, head/neck range of motion and strength, ocular motor control, quality of voice output and client's ability to use the accessibility components and systems) are identified and assessed. Multiple systems/components are tested to determine optimal interface between client and technology applications.

Appropriateness of commercial (off-the-shelf) components/systems is determined. The need for modification of commercial components/systems is assessed. Custom components/systems are designed and tested as needed for the patient.

Orthotic Management

Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies), and/or trunk, may be considered reasonable and necessary if there is an indication for education for the application of orthotics and the functional use of orthotics is present and documented in the patient's medical records maintained by the provider.

Prosthetic Training

Prosthetic(s) training may be considered reasonable and medically necessary if there is a documented indication for education for the application and functional use of the prosthetic in the patient's medical records maintained by the provider.

Checkout for Orthotic/Prosthetic Use, Established Patient

These assessments are medically necessary when a device is newly issued or when there is a modification or re-issue of the orthotic/prosthetic device.

These assessments may also be medically necessary when patients experience a loss of function directly related to the device (e.g., pain, skin breakdown, or falls).

Electrical Stimulation for the Treatment of Wounds

For services performed on or after April 1, 2003, Medicare will cover electrical stimulation for the treatment of wounds only for chronic stage III or stage IV pressure ulcers, arterial ulcers, diabetic ulcers, venous stasis ulcers, and non-pressure chronic ulcers. All other uses of electrical stimulation for the treatment of wounds are not covered by Medicare. Electrical stimulation will not be covered as an initial treatment modality. The use of electrical stimulation will only be covered after appropriate standard wound care has been tried for at least 30 days and there are no measurable signs of healing. If electrical stimulation is being used, wounds must be evaluated periodically by the treating physician or non-physician practitioner, but no less than every 30 days by a physician. Continued treatment with electrical stimulation is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment. Additionally, electrical stimulation must be discontinued when the wound demonstrates a 100 percent epithelialized wound bed.

Electrical Stimulation for Indications Other Than Wound Care

Electrical stimulation for indications other than wound care is considered medically necessary when performed as an integral part of the therapy plan of care.

This modality does not require direct (one-on-one) patient contact by the provider.

Complex Decongestive Physiotherapy

Complex decongestive physiotherapy (CDP) consists of skin care, manual lymph drainage, compression wrapping, and exercises.

The goal of this therapy is not to achieve maximum volume reduction, but to ultimately transfer the responsibility of the care from the clinic, hospital, or doctor, to home care by the patient, patient's family or patient's caregiver. Unless the patient is able to continue therapy at home, there is only temporary benefit from the treatment. The endpoint of treatment is not when the edema resolves or stabilizes, but when the patient and/or their cohort are able to continue the treatments at home. Patients who do not have the capacity or support system to accomplish these skills in a reasonable time are not good candidates for CDP.

The coverage of the CDP therapy would only be allowed if all of the following conditions have been met:

  • There is a physician documented diagnosis of lymphedema; and the physician specifically orders CDP.
  • The patient is symptomatic for lymphedema, with limitation of function related to self care, mobility and/or safety.
  • The patient or patient caregiver has the ability to understand and comply with home care continuation of treatment regimen.
  • The services are being performed by a health care professional who has received specialized training in this form of treatment.

Limitations

Vasopneumatic Devices

Further treatment of lymphedema by a provider after the educational visits are generally not medically necessary.

Education on the use of a lymphedema pump for home use can typically be completed in no more than three (3) visits.

The use of vasopneumatic devices would not be covered as a temporary treatment while awaiting receipt of ordered Jobst stockings.

Diathermy

Diathermy is not considered medically necessary for the treatment of asthma, bronchitis, or any other pulmonary condition.

Diathermy/Diapulse

High energy pulsed wave diathermy machines have been determined to produce the same therapeutic benefit as standard diathermy; therefore, any reimbursement for diathermy will be made at the same level as standard diathermy.

Diathermy/Microwave

Because there is no evidence from published, controlled clinical studies demonstrating the efficacy of this modality, this service will be denied as not reasonable and necessary.

Electrical Stimulation (Manual)

Standard treatment is 3 to 4 sessions a week for one month when used as adjunctive therapy or for muscle retraining. Additional sessions must meet medical necessity requirements.

Manual electrical stimulation should not be reported for wound care of any sort because wound care does not require constant attendance.

Ultrasound Application

Ultrasound Application is not considered to be medically necessary for the treatment of asthma, bronchitis, or any other pulmonary condition.

Standard treatment is 3-4 treatments per week for one month. Additional treatments must meet medical necessity requirements.

Community/Work Reintegration Training

Community reintegration is performed in conjunction with other therapeutic procedures such as gait training and self-care/home management training. The payment for community reintegration training is bundled into the payment for those other services. Therefore, these services are not separately reimbursable.

Services which are related solely to specific employment opportunities, work skills, or work settings are not reasonable and necessary and are excluded from coverage.

Wheelchair Management (e.g., assessment, fitting, training)

Typically 3-4 total sessions should be sufficient to teach the patient these skills. Medical necessity must support additional sessions.

Work Hardening/Conditioning

This service is not covered. These services are related solely to specific work skills, and they are not reasonable or necessary and are not covered.

Assistive Technology Assessment

Coverage is specifically for assessment of mobility and seating systems that require high level adaptation, not for routine seating and mobility systems (e.g., manual/power wheelchair evaluations).

Utilization of this service should be infrequent.

Orthotic Management

Orthotic(s) fitting and training, upper extremity(ies), lower extremity(ies), and/or trunk reflects the fitting as well as the training, as the training in the use of the orthotic is done at the time of the fitting. Typically, orthotic training can be completed in three (3) visits, but based on patient condition/status, may require additional visits. In addition, subsequent visits may be necessary for re-evaluation in modification of the orthotic and/or program. Additional training must meet medical necessity requirements.

Prosthetic Training

Periodic revisits beyond the third month must meet medical necessity requirements.

One would not expect to see more than 30 minutes of prosthetic training billed on a given date. Additional training must meet medical necessity requirements.

Checkout for Orthotic/Prosthetic Use, Established Patient

These assessments are not medically necessary when a device is replaced after normal wear.

Complex Decongestive Physiotherapy

It is expected that therapy education sessions would usually last for 1 to 2 weeks, with the patient attending 3-5 times per week, depending on the progress of the therapy. After that time, there should have been enough teaching and instruction that the care could be continued by the patient or patient caregiver in the home setting. The maximum benefits of treatment are not expected unless the patient continues treatment at home.

The therapy billed in conjunction with the manual lymph drainage therapy will be subject to all national and local policies for therapy services.

Currently, services for lymphedema are covered by the lymphedema pump. Some providers are proposing noninvasive complex lymphedema therapy as an alternative to pumps. A patient requiring both modes of treatment should be rare. In addition, it is not expected that PT and OT would be performed concurrently; (i.e., both PT and OT providing the therapeutic exercise portion of the session).

The therapy services for CDP must be provided either by or under the direct personal supervision of the physician or independently practicing therapist.

 

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.

Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Please refer to the Local Coverage Article: Billing and Coding: Therapy and Rehabilitation Services (A57156) for documentation requirements that apply to the reasonable and necessary provisions outlined in this LCD.

Utilization Guidelines

Please refer to the Local Coverage Article: Billing and Coding: Therapy and Rehabilitation Services (A57156) for utilization guidelines that apply to the reasonable and necessary provisions outlined in this LCD.

Sources of Information

First Coast Service Options, Inc. reference LCD numbers L29024, L29289, L29399

American Medical Association. (2013). Coderss Desk Reference for Procedures CPT code 97532.

Andrews, J. and Harrelson, G. Physical rehabilitation of the injured athlete. Philadelphia: W.B. Saunders Company.

Bollinger, K. (2004). Manual therapy can help patients progress to functional therapeutic exercise. Advance newsmagazines. PA: Merion Publications. This source was used to gain a better understanding of manual therapy.

Coster, W.J., Haley, S.M., Andres, P.L., Ludlow, L.H., & Bond, T.L. (2004). Refining the conceptual basis for rehabilitation outcome measurement: personal care and instrumental activities domain. Medical care, Jan; 42 (62-72). Boston, MA. This source compared ADL and IADL items with rehabilitation outcomes.

Grabois, M., McCann, M., Schramm, D., Straja, A., & Smith, K. (1996). Chronic pain syndromes: Evaluation and treatment. In R.L. Braddock (Ed.), Physical medicine and rehabilitation (pp. 876-891). Philadelphia, PA: W.B. Saunders Company. This source was used to establish indications and limitations.

Grandmaison, E, and Simard, M (2003). A critical review of memory stimulation programs in Alzheimer's Disease. The Journal of Neuropsychiatry and Clinical Neurosciences; 15 (2) pp:130-144.

Loewenstein, D., et al (2004). Cognitive rehabilitation of mildly impaired Alzheimer disease patients on cholinesterase inhibitors. American Journal of Geriatric Psychiatry, 12(4) pp 395-402.

Scifers, J. (2004). Among modalities, use iontophoresis to quickly relieve pain and inflammation. Advance newsmagazines. PA: Merion Publications. This source was used to gain a better understanding of iontophoresis therapy.

Tan, J.C. (1998). Practical manual of physical medicine and rehabilitation. St. Louis, MO: Mosby, Inc. This source was used to clarify the various modalities.

Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
03/31/2023 R16

This LCD is being retired effective for dates of service on and after 03/01/2023 as the IOM and applicable regulations will provide guidance in place of the LCD.

  • LCD Being Retired
10/01/2019 R15

Revision Number 10
Publication: September 2019 Connection
LCR A/B2019-058

Explanation of Revision: Based on Change Request (CR) 10901, the LCD was revised to remove all billing and coding and all language not related to reasonable and necessary provisions (“Bill Type Codes”, “Revenue Codes”, “CPT/HCPCS Codes”, “ICD-10 Codes that Support Medical Necessity”, “Documentation Requirements” and “Utilization Guidelines” sections of the LCD) and place them into a newly created billing and coding article. During the process of moving the ICD-10-CM diagnosis codes to the billing and coding article, the ICD-10-CM diagnosis code ranges were broken out and listed individually. In addition, the Social Security Act, Code of Federal Regulations, and IOM reference sections were updated. Also, the CMS IOM language has been removed from the LCD and instead, the IOM citation related to this language is referenced. The effective date of this revision is for claims processed on or after January 8, 2019, for dates of service on or after October 3, 2018.

Based on CR 11322/CR 11333 (Annual 2020 ICD-10-CM Update) the newly created Billing and Coding Article was revised. Descriptor revised for ICD-10-CM diagnosis code J44.0. The effective date of this revision is for dates of service on or after 10/01/19.

10/01/2019: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this LCD.

  • Revisions Due To ICD-10-CM Code Changes
  • Other (Revisions based on CRs 10901, 11322, 11333)
01/01/2019 R14

Revision Number: 9
Publication: December 2018 Connection
LCR A/B2019-001

Explanation of revision: Annual 2019 HCPCS Update. Deleted CPT code 96111. Also, due to the change in the descriptor for CPT code 96116 it was removed from the LCD. Also, grammatical and spelling errors were corrected. In addition, based on CR 10784 the “Functional Reporting” section of the LCD was deleted. The effective date of this revision is based on date of service.

01/01/2019: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this LCD.

  • Revisions Due To CPT/HCPCS Code Changes
04/24/2018 R13

Revision Number: 8

Publication: May 2018 Connection

LCR A/B2018-040

Explanation of revision:  Based on an annual review of the LCD, it was determined that some of the italicized language in the “Coverage Indications, Limitations, and/or Medical Necessity” and “Documentation Requirements” sections of the LCD do not represent direct quotation from CMS sources listed in the LCD; therefore, this LCD is being revised to assure consistency with the CMS sources. The effective date of this revision is based on date of service.

04/24/2018:  At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice.  This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Revisions based on annual review completed on 12/20/2017.)
02/23/2018 R12

Revision Number: 7

Publication: March 2018 Connection

LCR A/B2018-025

Explanation of revision:  Section 50202 of the Bipartisan Budget Act repeals Medicare provisions affecting the outpatient therapy caps. This section requires that Medicare claims no longer be subject to the therapy cap. Therefore, the “Indications and Limitations of Coverage and/or Medical Necessity,” “CPT/HCPCS Codes,” and “ICD-10 Codes that Support Medical Necessity” sections of the LCD were revised to remove language related to the therapy cap. The effective date of this revision is based on claims processed on or after February 23, 2018, for dates of service on after January 1, 2018. Also, based on CR10318 (NCD 270.1), the LCD was revised to add non-pressure chronic ulcers as covered for HCPCS code G0281 in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the LCD. The effective date of this revision is based on claims processed on or after April 2, 2018, for dates of service on after October 1, 2017.

02/23/2018:  At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice.  This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
  • Public Education/Guidance
01/01/2018 R11

Revision Number: 6

Publication: December 2017 Connection

LCR A/B2018-011

Explanation of revision:  Annual 2018 HCPCS update and CR 10303 (2018 Annual Update to the Therapy Code List). Descriptor revised for CPT codes 97760 and 97761. Also, CPT code 97532 was deleted and replaced with HCPCS code G0515 and CPT code 97762 was deleted and replaced with CPT code 97763. The effective date of this revision is based on date of service.  In addition, a determination was made to remove unlisted CPT codes 97039, 97139, and 97799 from the “Indications and Limitations of Coverage and/or Medical Necessity” and “CPT/HCPCS Codes” sections of the LCD. The language related to “Unlisted Modalities” was also removed from the “Documentation Requirements” section of the LCD. The effective date of this revision is based on process date.

01/01/2018:  At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice.  This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To CPT/HCPCS Code Changes
10/01/2017 R10

Revision Number: 5

Publication: September 2017 Connection 

LCR A/B2017-038 

Explanation of Revision: Based on CR 10153 (Annual 2018 ICD-10-CM Update) the LCD was revised. Descriptor revised for ICD-10-CM diagnosis codes M33.01, M33.11 for procedure codes 97024, 97035. The effective date of this revision is based on date of service.

10/01/2017:  At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice.  This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To ICD-10-CM Code Changes
01/20/2017 R9 Revision Number: 4 Publication: January 2017 Connection
LCR A/B2017-003

Explanation of Revision: The LCD was revised based on CR 9861 to remove all associated language and diagnosis codes for CPT code 97026 as infrared therapy is noncovered for all indications. The effective date of this revision is for claims processed on or after 01/20/2017 for dates of service on or after 10/01/2015.
  • Other
01/20/2017 R8 Revision Number: 4 Publication: January 2017 Connection
LCR A/B2017-003

Explanation of Revision: The LCD was revised based on CR 9861 to remove all associated language and diagnosis codes for CPT code 97026 as infrared therapy is noncovered for all indications. The effective date of this revision is for claims processed on or after 01/20/2017 for dates of service on or after 10/01/2015.
  • Revisions Due To ICD-10-CM Code Changes
  • Revisions Due To CPT/HCPCS Code Changes
01/01/2017 R7 Revision Number: 3 Publication: December 2016 Connection
LCR A/B2017-001

Explanation of Revision: Annual 2017 HCPCS Update. LCD was revised to add CPT codes 97161-97168. Additionally, LCD was revised to delete CPT codes 97001-97004. The effective date of this revision is based on date of service.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2016 R6 Revision Number: 2 Publication: October 2016 Connection
LCR A/B2016-097

Explanation of Revision: Based on CR 9677 (Annual 2017 ICD-10-CM Update) the LCD was revised. Added ICD-10-CM diagnosis codes G56.43, G56.93, G57.13, G57.23, G57.33, G57.43, G57.63, G57.73, G57.83, and G57.93 to current ranges and added diagnosis code G61.82 for CPT 97026. Revised ICD-10-CM diagnosis code Z98.89 to read Z98.890 for CPT code 97116. The effective date of this revision is based on date of service. Additionally, ICD-10 diagnosis codes for Complex Decongestive Physiology were removed from LCD section,’ICD-10 Codes That Support Medical Necessity’ given these diagnosis codes can be billed for other services. The effective date of this revision is based on process date.

  • Revisions Due To ICD-10-CM Code Changes
03/15/2016 R5 Revision Number: 1
Publication: N/A
LCR A/B2016-054

Explanation of revision: Based on an internal request to clarify language in the LCD under the Documentation section in the LCD pertinent to CPT code 97750, the LCD has been revised to clarify this section. The effective date of this revision is based on date of service.
  • Reconsideration Request
10/01/2015 R4 8/28/15 The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.
  • Provider Education/Guidance
10/01/2015 R3 correction to formatting.
  • Other
10/01/2015 R2 10/21/2014- Formatting corrected.
  • Other
10/01/2015 R1 06/05/2014 – The language and/or ICD-10-CM diagnoses were updated to be consistent with current LCD language and ICD-9-CM coding.
  • Revisions Due To ICD-10-CM Code Changes
N/A

Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
03/31/2023 10/01/2019 - 03/01/2023 Retired You are here
10/02/2019 10/01/2019 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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