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):

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, dietitiansFootnotes**, respiratory therapistsFootnotes**, 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).

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.

Footnotes**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.

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 0198 - Work Hardening Programs, and 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.

Code Code Description

The above policy is based on the following references:

  1. American Diabetes Association (ADA). Diabetes Education Goals. Practical Approaches in Diabetes Care. Alexandria, VA: ADA, 1995.
  2. American Occupational Therapy Association. Work hardening guidelines. Am J Occup Ther. 1986;40(12):841-843.
  3. 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.
  4. Brady TJ, Murphy L, O'Colmain BJ, et al. A meta-analysis of health status, health behaviors, and healthcare utilization outcomes of the Chronic Disease Self-Management Program. Prev Chronic Dis. 2013;10:120112.
  5. Celli BR. Pulmonary rehabilitation in patients with COPD. Am J Respir Crit Care Med. 1995;152(3):861-864.
  6. Drenkard C, Dunlop-Thomas C, Easley K, et al. Benefits of a self-management program in low-income African-American women with systemic lupus erythematosus: Results of a pilot test. Lupus. 2012;21(14):1586-1593.
  7. Fletcher GF. Current status of cardiac rehabilitation. Am Fam Physician. 1998;58(8):1778-1182.
  8. Franek J. Self-management support interventions for persons with chronic disease: An evidence-based analysis. Ont Health Technol Assess Ser. 2013;13(9):1-60.
  9. Funnell MM, Haas LB. National standards for diabetes self-management education programs. Diabetes Care. 1995;18(1):100-116.
  10. Glasow RE. A practical model of diabetes management and education. Diabetes Care. 1995;18(1):117-126.
  11. Hotta SS. Cardiac rehabilitation programs. Health Technol Assess Rep. 1991;(3):1-10.
  12. 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.
  13. Lechner DE. Work hardening and work conditioning interventions: Do they affect disability? Phys Ther. 1994;74(5):471-493.
  14. Linton SJ, Kamwendo K. Low back schools. A critical review. Phys Ther. 1987;67(9):1375-1383.
  15. Mahler DA. Pulmonary rehabilitation. Chest. 1998;113(4 Suppl):263S-268S.
  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. 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.
  18. Mooney V, Hughson WG. Resurgence of work-hardening programs. West J Med. 1992;156(4):410.
  19. Nicholas MK, Asghari A, Blyth FM, et al. Self-management intervention for chronic pain in older adults: A randomised controlled trial. Pain. 2013;154(6):824-835.
  20. Nordin M, Cedraschi C, Balague F, Roux EB. Back schools in prevention of chronicity. Baillieres Clin Rheumatol. 1992;6(3):685-703.
  21. Ory MG, Ahn S, Jiang L, et al. National study of chronic disease self-management: Six-month outcome findings. J Aging Health. 2013;25(7):1258-74.
  22. Revel M. Rehabilitation of low back pain patients. A review. Rev Rhum Engl Ed. 1995;62(1):35-44.
  23. 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.
  24. Shoor S, Lorig KR. Self-care and the doctor-patient relationship. Med Care. 2002;40(4 Suppl):II40-II44.
  25. 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.
  26. 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.
  27. Wolf FM, Guevara JP, Grum CM, et al. Educational interventions for asthma in children. Cochrane Database Syst Rev. 2003;(1):CD000326.