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Clinical Policy Bulletin:
Outpatient Medical Self-Care Programs
Number: 0169


Policy

Aetna considers the following outpatient medical self-care programs medically necessary (subject to applicable plan coverage definitions and limitations; please check benefit plan descriptions for details):

Note on Recognized Programs:

Consideration of coverage will be extended to other medically necessary self-care programs (subject to plan coverage definitions and limitations; please check benefit plan descriptions) when:

  • The program consists of services provided by recognized health care professionals (e.g., doctors, registered nurses, social workers, physical therapists, dietitians**, respiratory therapists**, etc.); and
  • The program is coordinated with Aetna's Patient Management Department (in Aetna network plans); and
  • The program is designed to educate the member about specific conditions and lifestyle changes necessary as a result of the medical condition; and
  • The program is directed and supervised by a physician; and
  • The program is prescribed by the attending physician for a member with a medical condition amenable to self-care (e.g., diabetes, chronic back pain, chronic pulmonary disease or cardiac disease).

Frequency and Duration:

The medically necessary frequency and duration of self-care programs varies depending on the goals and objectives of the program.

Aetna considers participation in a self-care program for a particular illness medically necessary once per lifetime unless an additional episode of illness requires another self-care program (e.g., second heart attack).

Note on Non-Covered Programs:

Coverage is not extended for self-care programs that:

  • Are available to the general public without charge; or
  • Are general health or lifestyle education programs -- not related to the member's diagnosis or condition; or
  • Consist of services not generally accepted as necessary and appropriate for management of the disease or injury.

**Note on Services Provided by Dietitians and Respiratory Therapists:

Self-care programs offering services provided by dietitians and respiratory therapists may be covered when required by law or when all of the following criteria are met:

  • The charges are billed by their doctor or hospital employer; and
  • The services are covered under the policy; and
  • They are employed by and working under the supervision of a hospital or recognized health care facility, a home health care agency or a qualified doctor; and
  • They are licensed, certified or qualified by professional credentials or degree to provide the services.

Note on Work Hardening Programs (see CPB 0198 - Work Hardening Programs):

Work hardening programs are not considered covered outpatient self-care programs under Aetna medical plans.  The primary goal of these programs is return to work, not treatment of a disease or injury.  Their purpose is training the individual to work with their current limitations and to be able to function with maximum productivity in their job.  This is a form of vocational rehabilitation rather than a covered outpatient self-care program.

See also CPB 0342 - Intestinal Rehabilitation Programs.



Background

Outpatient medical self-care programs refer to programs that focus on self-care activities for management of disease.  Self-care programs follow evidence based guidelines, and may refer to diet, exercise, administration of medications, monitoring disease, avoiding activities that exacerbate disease, and obtaining recommended follow-up medical care.  Another important part of self-care is being able to recognize the need for medical care.



The above policy is based on the following references:
  1. Wegner NK, Froelicher ES, Smith LK, et al. Cardiac Rehabilitation. Clinical Practice Guideline No. 17. AHCPR Pub. No. 96-0672. Rockville, MD: Agency for Health Care Policy and Research (AHCPR); October 1995.
  2. Fletcher GF. Current status of cardiac rehabilitation. Am Fam Physician. 1998;58(8):1778-1182.
  3. Hotta SS. Cardiac rehabilitation programs. Health Technol Assess Rep. 1991;(3):1-10.
  4. Mahler DA. Pulmonary rehabilitation. Chest. 1998;113(4 Suppl):263S-268S.
  5. Celli BR. Pulmonary rehabilitation in patients with COPD. Am J Respir Crit Care Med. 1995;152(3):861-864.
  6. Bigos S, Boyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research (AHCPR); December 1994.
  7. Nordin M, Cedraschi C, Balague F, Roux EB. Back schools in prevention of chronicity. Baillieres Clin Rheumatol. 1992;6(3):685-703.
  8. Revel M. Rehabilitation of low back pain patients. A review. Rev Rhum Engl Ed. 1995;62(1):35-44.
  9. Linton SJ, Kamwendo K. Low back schools. A critical review. Phys Ther. 1987;67(9):1375-1383.
  10. Glasow RE. A practical model of diabetes management and education. Diabetes Care. 1995;18(1):117-126.
  11. Funnell MM, Haas LB. National standards for diabetes self-management education programs. Diabetes Care. 1995;18(1):100-116.
  12. American Diabetes Association. Diabetes Education Goals. Practical Approaches in Diabetes Care. Alexandria, VA: ADA, 1995.
  13. Lechner DE. Work hardening and work conditioning interventions: Do they affect disability? Phys Ther. 1994;74(5):471-493.
  14. Mooney V, Hughson WG. Resurgence of work-hardening programs. West J Med. 1992;156(4):410.
  15. American Occupational Therapy Association. Work hardening guidelines. Am J Occup Ther. 1986;40(12):841-843.
  16. Matheson LN, Ogden LD, Violette K, Schultz K. Work hardening: Occupational therapy in industrial rehabilitation. Am J Occup Ther. 1985;39(5):314-321.
  17. Shoor S, Lorig KR. Self-care and the doctor-patient relationship. Med Care. 2002;40(4 Suppl):II40-II44.
  18. Miller CK, Edwards L, Kissling G, et al. Nutrition education improves metabolic outcomes among older adults with diabetes mellitus: Results from a randomized controlled trial. Prev Med. 2002;34(2):252-259.
  19. Wolf FM, Guevara JP, Grum CM, et al. Educational interventions for asthma in children. Cochrane Database Syst Rev. 2003;(1):CD000326.
  20. Rootmensen GN, van Keimpema AR, Looysen EE, et al. The effects of additional care by a pulmonary nurse for asthma and COPD patients at a respiratory outpatient clinic: Results from a double blind, randomized clinical trial. Patient Educ Couns. 2008;70(2):179-186.
  21. Jerant A, Moore-Hill M, Franks P. Home-based, peer-led chronic illness self-management training: Findings from a 1-year randomized controlled trial. Ann Fam Med. 2009;7(4):319-327.
  22. van der Meer V, Bakker MJ, van den Hout WB, et al; SMASHING (Self-Management in Asthma Supported by Hospitals, ICT, Nurses and General Practitioners) Study Group. Internet-based self-management plus education compared with usual care in asthma: A randomized trial. Ann Intern Med. 2009;151(2):110-120.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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