Highmark Medicare Advantage Medical Policy in West Virginia

Section:	Therapy
Number:	Y-1
Topic:	Physical Medicine and Rehabilitation Services, PT and OT
Effective Date:	December 12, 2008
Issued Date:	May 25, 2009

General Policy

Archived May 25, 2009

This policy on Physical Medicine and Rehabilitation Services, PT and OT has been archived as of May 25, 2009 and is no longer in effect. For services rendered prior to the archived date of this policy, please refer to the prior versions of the policy.

Indications and Limitations of Coverage

Procedure Codes

97001	97002	97003	97004	97010	97012
97014	97016	97018	97022	97024	97026
97028	97032	97033	97034	97035	97036
97039	97110	97112	97113	97116	97124
97139	97140	97150	97530	97532	97533
97535	97537	97542	97545	97546	97750
97755	97760	97761	97762	97799	G0283
S8990

Procedure Code Attachments

Diagnosis Codes

Glossary

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.