Aetna considers physical therapy medically necessary when this care is prescribed by a doctor in order to significantly improve, develop or restore physical functions lost or impaired as a result of a disease, injury or surgical procedure.

Once therapeutic benefit has been achieved, or a home exercise program could be used for further gains, continuing supervised physical therapy is not considered medically necessary.

Physical therapy in asymptomatic persons or in persons without an identifiable clinical condition is considered not medically necessary.

Physical therapy in persons whose condition is neither regressing nor improving is considered not medically necessary.

Notes: Aetna HMO and POS plans generally cover only short-term physical therapy when the member is likely to gain significant improvement from therapy applied over this period of time. Because of this short-term restriction, these plans do not cover ongoing physical therapy in the management of individuals with chronic diseases, except as indicated in our coverage rules. In most cases, this short-term limitation does not apply to Indemnity and PPO plans. Standard Managed Choice plans cover up to 60 physical therapy visits or sessions per calendar year. Please check benefit plan descriptions for details.

Physical therapy may require precertification in some plan designs. Subject to plan benefit descriptions, physical therapy may be a limited benefit.

Typically, in Aetna HMO plans, the physical therapy benefit is limited to a 60-day treatment period. When this is the case, the treatment period of 60 days applies to a specific condition. In some plan designs this limitation is applied on a calendar year or on a contract-year basis. In others it is a lifetime limitation. Please check benefit plan descriptions for details. Regardless, it is possible for a member to receive more than one 60-day treatment course of physical therapy as treatment of separate conditions. For example, a surgical procedure causing the need for physical therapy is considered to be the initiation of a new or separate condition in a person who previously received physical therapy for another indication, and so qualifies the member to receive coverage for an additional course of physical therapy as outlined above. An exacerbation or flare-up of a chronic illness is not considered a new incident of illness.

In some plans, the available physical therapy benefit is defined by a number of treatment sessions covered per year regardless of the condition or number of courses of therapy indicated.

Standard Aetna policies exclude coverage for services, treatment, education testing, or training related to learning disabilities or developmental delays. Under plans with this exclusion, physical therapy is not covered when the primary or the only diagnosis for a member is mental retardation or a learning disability such as a perceptual handicap, brain damage not caused by accidental injury, minimal brain dysfunction, dyslexia, or developmental delay. Please check benefit plan descriptions for details.

Home-Based Physical Therapy:

Aetna considers home-based physical therapy medically necessary in selected cases based upon the member's needs. This may be considered medically necessary in the transition of the member from hospital to home and is an extension of case management services.

Note: In Aetna HMO and QPOS plans, such short-term physical therapy accumulates towards the 60-day limit or other applicable rehabilitation benefit limits. Please check benefit plan descriptions for details.

The Interactive Metronome Program:

Aetna considers the Interactive Metronome program experimental and investigational because there is insufficient evidence to support its effectiveness.

Augmented Soft Tissue Mobilization:

Augmented soft tissue mobilization has not been proven to be more effective than standard soft tissue mobilization. There is no reliable evidence that outcomes of soft tissue mobilization (myofascial release) are improved with the use of hand-held tools (so-called "augmented soft tissue mobilization").

Physical therapy treatment consists of a prescribed program to relieve symptoms, improve function and prevent further disability for individuals disabled by chronic or acute disease or injury. Treatment may include various forms of heat and cold, electrical stimulation, therapeutic exercises, ambulation training and training in functional activities.

Medically necessary physical therapy services must be restorative or for the purpose of designing and teaching a maintenance program for the patient to carry out at home. The services must also relate to a written treatment plan and be of a level of complexity that requires the judgment, knowledge and skills of a physical therapist (or a medical doctor/doctor of osteopathy) to perform and/or supervise the services. The amount, frequency and duration of the physical therapy services must be reasonable, the services must be considered appropriate and needed for the treatment of the disabling condition and must not be palliative in nature.

Below is a description and medical necessity criteria for different treatment modalities and therapeutic procedures.

1. Activities of Daily Living (ADL) Training - Training of severely impaired individuals in essential activities of daily living, including bathing; feeding; preparing meals; toileting; walking; making bed; and transferring from bed to chair, wheelchair or walker. This procedure is considered medically necessary to enable the member to perform essential activities of daily living related to the patient's health and hygiene, within or outside the home, with minimal or no assistance from others. This procedure is considered medically necessary only when it requires the professional skills of a provider, is designed to address specific needs of the member, and must be part of an active treatment plan directed at a specific outcome. The member must have the capacity to learn from instructions. Standard medical treatment may generally require up to 12 visits in 4 weeks. Services provided concurrently by physicians, physical therapists and occupational therapists may be considered medically necessary if there are separate and distinct functional goals.

2. Aquatic Therapy/Hydrotherapy/Hubbard Tank - Hubbard tank involves a full-body immersion tank for treating severely burned, debilitated and/or neurologically impaired individuals. Pool therapy (aquatic therapy, hydrotherapy) is provided individually, in a pool, to severely debilitated or neurologically impaired individuals. (The term is not intended to refer to relatively normal individuals who exercise, swim laps or relax in a hot tub or Jacuzzi.) Develops and/or maintains muscle strength including range of motion by eliminating forces of gravity through total body immersion (except for head) - requires constant attention. It is not considered medically necessary to provide more than one type of hydrotherapy on the same day (e.g., whirlpool, Hubbard tank, hydrotherapy). For medical necessity criteria, see CPB 174 - Pool Therapy, Aquatic Therapy or Hydrotherapy.

3. Cognitive skills development - This procedure is considered medically necessary for persons with acquired cognitive defects resulting from head trauma, or acute neurologic events including cerebrovascular accidents. It is not appropriate for persons with chronic progressive brain conditions with no potential for restoration. Occupational/speech therapists or clinical psychologists with specific training in these skills are typically the providers. This procedure should be aimed at improving or restoring specific functions which were impaired by an identified illness or injury. The goals of therapy, expected outcomes and expected duration of therapy should be specified.

4. Contrast Baths - Blood vessel stimulation with alternate hot and cold baths - constant attendance is needed. This modality may be considered medically necessary to treat extremities affected by reflex sympathetic dystrophy, acute edema resulting from trauma, or synovitis/tenosynovitis. It is generally used as an adjunct to a therapeutic procedure. Standard treatment is 3-4 treatments per week for one month.

5. Crutch/Cane Ambulation - Ambulation training ad re-education with the use of assistive devices such as cane or crutches. Considered medically necessary for persons who meet medical necessity criteria for ambulatory assist devices. See CPB 505 - Ambulatory Assist Devices: Walkers, Canes and Crutches.

6. Diathermy - Deep, dry heat with high frequency current to relieve pain and increase movement - supervised. The objective of is to cause vasodilatation and relieve pain from muscle spasm. Diathermy achieves a greater rise in deep tissue temperature than does microwave. Considered medically necessary as a heat modality for painful musculoskeletal conditions.

7. Electrical Stimulation - For medical necessity criteria, see CPB 011 - Electrical Stimulation for Pain; CPB 680 - Electrical Stimulation for Chronic Ulcers; and CPB 677 - Functional Electrical Stimulation and Neruomuscular Electrical Stimulation.

8. Gait Training - Teaching individuals with severe neurological or musculoskeletal disorders to ambulate in the face of their handicap or to ambulate with an assistive device. Gait training is considered medically necessary for training individuals whose walking abilities have been impaired by neurological, muscular or skeletal abnormalities or trauma. Gait training is not considered medically necessary when the individual's walking ability is not expected to improve. Provider supervision of repetitive walk-strengthening exercise for feeble or unstable patients is not considered medically necessary. Gait training is not considered medically necessary for relatively normal individuals with minor or transient abnormalities of gait who do not require an assistive device; these minor or transient gait abnormalities may be remedied by simple instructions to the individual.

9. Hot/Cold Packs - Hot packs increases blood flow, relieves pain and increases movement; cold packs decreases blood flow to an area to reduce pain and swelling immediately after an injury. These are used in Contrast Therapy under supervision. Considered medically necessary as thermal modalities (hot or cold) for painful musculoskeletal conditions and for acute injuries. See also CPB 297 - Cryoanalgesia and Therapeutic Cold.

10. Infrared Light Therapy - Dry heat with a special lamp to increase circulation to an area under supervision. The objective is to cause vasodilatation and relieve pain from muscle spasm. Considered medically necessary as a heat modality for musculoskeletal indications. See also CPB 540 - Heating Devices; and CPB 604 - Infrared Therapy.

11. Iontophoresis - Electric current used to transfer certain chemicals (medications) into body tissues. For medical necessity criteria, see CPB 229 - Iontophoresis.

12. Kinetic Therapy - Use of dynamic activities to improve functional performance. Considered medically necessary when there are major impairments or disabilities which preclude the individual performing the activities and exercises that are ordinarily prescribed. In kinetic therapy, considerable time is spent developing specific, individualized therapeutic exercises and instructing the patient in how to perform them. The term kinetic therapy is not intended to apply to instructions in routine exercises. It is not considered medically necessary to provide kinetic therapy, therapeutic exercises and/or neuromuscular reeducation on the same day.

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

14. Microwave - The objective of this treatment is to cause vasodilatation and relieve pain from muscle spasm. Considered medically necessary as a heat modality for painful musculoskeletal conditions.

15. Myofascial Release - Soft tissue mobilization through manipulation. Skilled manual techniques (active and/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, restoration of movement in acutely edematous muscles, or stretching of shortened connective tissue. This procedure is considered medically necessary for treatment of restricted motion of soft tissues in involved extremities, neck, and trunk.

16. Neuromuscular Re-education - This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception to a person who has had muscle paralysis and is undergoing recovery or regeneration. Goal is to develop conscious control of individual muscles and awareness of position of extremities. The procedure may be considered medically necessary for impairments which affect the body's neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, hypo/hypertonicity) that may result from disease or injury such as severe trauma to nervous system, cerebral vascular accident and systemic neurological disease. Standard treatment is 12 to 18 visits within a 4-6 week period. It is not considered medically necessary to provide neuromuscular reeduction, kinetic therapy, and/or therapeutic exercises on the same day.

17. Orthotic Training - Training and re-education with braces and/or splints (orthotics). Considered medically necessary for persons who meet criteria for a brace or splint. See CPB 009 - Orthopedic Casts, Braces and Splints. There should be distinct treatments rendered when orthotic training for a lower extremity is done during the same visit as gait training, or self-care/home management training. It is unusual to require more than 30 minutes of static orthotics training. In some cases, dynamic training may require additional time.

18. Paraffin Bath - Also known as hot wax treatment, this involves supervised application of heat (via hot wax) to an extremity to relieve pain and facilitate movement. This is considered medically necessary for pain relief in chronic joint problems of the wrists, hands or feet. One or two visits is usually sufficient to educate the individual in home use and to evaluate effectiveness. See also CPB 540 - Heating Devices.

19. Prosthetic checkout - These assessments are considered medically necessary when a device is newly issued or there is a modification or re-issue of the device. These assessments are considered medically necessary when member experiences loss of function directly related to the orthotic or prosthetic device (e.g., pain, skin breakdown, or falls. Usually, no more than 30 minutes of time is necessary.

20. Prosthetic Training - Training and re-education with artificial devices (prosthetics). Considered medically necessary for persons with a medically necessary prosthetic. There should be distinct goals and services rendered when prosthetic training for a lower extremity is done during the same visit as gait training or self care/home management training. Periodic revisits beyond the third month may be reviewed for medical necessity. It is unusual to require more than 30 minutes of prosthetic training on a given date.

21. Therapeutic activities - This procedure involves using 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 provider and are designed to address a specific functional need of the member. These dynamic activities must be part of an active treatment plan and directed at a specific outcome.

22. Therapeutic Exercises - Instructing a person in exercises and directly supervising the exercises. Purpose is to develop and/or maintain muscle strength including range of motion, stretching and postural drainage. Therapeutic exercise is performed with a patient either actively, active-assisted, or passively (e.g., treadmill, isokinetic exercise lumbar stabilization, stretching, strengthening). Therapeutic exercise is considered medically necessary for loss or restriction of joint motion, strength, functional capacity or mobility which has resulted from disease or injury. Standard treatment is 12 to 18 visits within a 4-6 week period. Note: Exercising done subsequently by the member without a physician or therapist present and supervising would not be covered. It is not considered medically necessary to perform therapeutic exercises, kinetic therapy, and/or neuromuscular reeducation on the same day.

23. Traction - Manual or mechanical pull on extremities or spine to relieve spasm and pain - supervised. Considered medically necessary for chronic back or neck pain. This modality, when provided by physicians or physical therapists, is typically used in conjunction with therapeutic procedures, not as an isolated treatment. Standard treatment is to provide supervised mechanical traction up to four sessions per week. For cervical radiculopathy, treatment beyond one month can usually be accomplished by self-administered mechanical traction in the home. See also CPB 453 - Cervical Traction Devices, and CPB 569 - Lumbar Traction Devices.

24. Ultrasound - Deep heat by high frequency sound waves to relieve pain, improve healing - constant attendance. This modality is considered medically necessary to treat arthritis, inflammation of periarticular structures, neuromas, and to soften adhesive scars. Standard treatment is 3-4 treatments per week for one month.

25. Vasopneumatic Device - Pressure application by special equipment to reduce swelling - supervised. It may be considered necessary to reduce edema after acute injury. Education for use of lymphedema pump in the home usually requires 1 or 2 sessions. Further treatment of lymphedema by the provider after the educational visits are generally not considered medically necessary. See also CPB 069 - Lymphedema Treatments and CPB 062 - Burn Garments.

26. Wheelchair management training - This procedure is considered medically necessary only when it requires the professional skills of a provider, is designed to address specific needs of the member, and must be part of an active treatment plan directed at a specific goal. The member must have the capacity to learn from instructions. Typically, 3 to 4 total sessions are sufficient.

27. Whirlpool - These modalities involve supervised use of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds e.g., ulcers, exfoliative skin conditions. Considered medically necessary to relieve pain and promote relaxation to facilitate movement in persons with musculoskeletal conditions. Also considered medically necessary for wound cleansing. It is not considered medically necessary to provide more than one hydrotherapy modality (e.g, whirlpool, Hubbard tank, aquatic therapy) performed on the same day. See also CPB 450 - Fluidized Therapy (Fluidotherapy); CPB 429 - Bathroom and Toilet Equipment and Supplies; and CPB 699 - Dry Hydrotherapy (Hydromassage, Aquamassage, Water Massage).

Certain physical medicine modalities are considered duplicative in nature and it would be inappropriate to perform or bill for these services during the same session, such as:

1. Microwave and diathermy
2. Neuromuscular re-education and therapeutic exercises
3. Whirlpool and Hubbard tank
4. Infrared and ultraviolet
5. Microwave and infrared
6. Kinetic activities and therapeutic exercises
7. Functional activities and ADL
8. Orthotics training and prosthetic training
9. Massage therapy and myofascial release.

Only one heat modality would be considered medically necessary during the same treatment session. An exception to this is ultrasound (a deep heat), which may be considered medically necessary with one superficial heat modality but is not considered medically necessary with other deep heat modalities.

Physical therapy should be provided in accordance with an ongoing, written plan of care. The purpose of the written plan of care is to assist in determining medical necessity and should include the following:

The written plan of care should be sufficient to determine the medical necessity of treatment, including:

1. The diagnosis along with the date of onset or exacerbation of the disorder/diagnosis;
   
   
   1. Physical therapy evaluation;
   2. Long-term and short-term goals that are specific, quantitative and objective;
   3. A reasonable estimate of when the goals will be reached;
   4. The specific treatment techniques and/or exercises to be used in treatment; and
   5. The frequency and duration of treatment.
      
      
2. Signatures of the patient's attending physician and physical therapist.
   
   
   1. The plan of care should be ongoing, (i.e., updated as the patient's condition changes), and treatment should demonstrate reasonable expectation of improvement (as defined below):
      
      
      1. Physical therapy services are considered medically necessary only if there is a reasonable expectation that physical therapy will achieve measurable improvement in the patient's condition in a reasonable and predictable period of time.
      2. The patient should be reevaluated regularly, and there should be documentation of progress made toward the goals of physical therapy.

The treatment goals and subsequent documentation of treatment results should specifically demonstrate that physical therapy services are contributing to such improvement.

The Interactive Metronome program:

The Interactive Metronome (IM) program is designed for processing speed, focus, as well as coordination. Trainees wear headphones and hear a fixed, repeating reference beat; they press against a hand or foot sensor to try to match it, while receiving visual and auditory feedback. The IM program has been promoted as a treatment for children with attention-deficit hyperactivity disorder (ADHD) and for other special needs children to increase concentration, focus, and coordination. It has also been promoted to improve athletic performance, to assess and improve academic performance of normal children, and to improve children's performance in the arts (e.g., dance, music, theater, creative arts). Furthermore, the IM program has also been implemented as part of a therapy program for patients with balance disorders, cerebrovascular accident, limb amputation, multiple sclerosis, Parkinson's disease, and traumatic brain injury.

Schaffer et al (2001) examined the effects of the IM program on selected aspects of motor and cognitive skills in a group of children with ADHD. The study included 56 boys who were 6 years to 12 years of age and diagnosed before they entered the study as having ADHD. The participants were pre-tested and randomly assigned to one of three matched groups. A group of 19 participants receiving 15 hours of IM training exercises were compared with a group receiving no intervention and a group receiving training on selected computer video games. A significant pattern of improvement across 53 of 58 variables favoring the IM program was found. Additionally, several significant differences were found among the treatment groups and between pre-treatment and post-treatment factors on performance in areas of attention, motor control, language processing, reading, and parental reports of improvements in regulation of aggressive behavior. The authors concluded that the IM program appears to facilitate a number of capacities, including attention, motor control, and selected academic skills, in boys with ADHD.

In a case report, Bartscherer and Dole (2005) described the use of the IM program for improving timing and coordination in a 9-year-old boy who had difficulties in attention and developmental delay of unspecified origin. The subject underwent a 7-week training with the program. Before, during, and after training, timing accuracy was evaluated with testing procedures consistent with the IM training protocol. Before and after training, the subject's gross and fine motor skills were examined with the Bruininiks-Oseretsky Test of Motor Proficiency (BOTMP). The child exhibited marked change in scores on both timing accuracy and several BOTMP subtests. Additionally his mother relayed anecdotal reports of changes in behavior at home. This child's participation in a new intervention for improving timing and coordination was associated with changes in timing accuracy, gross and fine motor abilities, and parent reported behaviors. The authors noted that these findings warrant further study.

Currently, there is insufficient evidence in the peer-reviewed medical literature to support the effectiveness of the IM program. Randomized controlled studies are needed to establish the clinical value of this program.

Augmented Soft Tissue Mobilization:

Augmented soft tissue mobilization (ASTM), a non-invasive mobilization technique, is used by chiropractors as well as massage, occupational, and physical therapists to treat chronic musculoskeletal disorders that result from scarring and fibrosis. It entails the use of hand-held tools made from bone or stone or metal and a lubricant on the skin to scrape and mobilize scar tissue.  Scraping is done to promote circulation, thus, promoting healing. Manual and other treatments may also be used with exercise to guide the healing process. Treatments with ASTYM are often administered on non-consecutive days, 1 to 2 times per week. A typical 30-minute session usually includes 15 minutes of treatment and 15 minutes of exercise and assessment. Less severe conditions reportedly can respond well in 2 to 4 sessions whereas difficult chronic cases may require 8 to16 sessions. However, there is insufficient evidence to support the effectiveness of ASTM.

In a case report, Melham et al (1998) described their finding on the use of ASTM in the treatment of excessive scar tissue around an athlete's injured ankle. Surgery and several months of conventional physical therapy failed to alleviate the athlete's symptoms. As a final resort, ASTM was administered. It used ergonomically designed instruments that assist therapists in the rapid localization and effective treatment of areas exhibiting excessive soft tissue fibrosis; followed by a stretching and strengthening program. Upon the completion of 6 weeks of ASTM, the athlete had no pain and had regained full range of motion and function.