Medical policy: Investigational Physical Medicine and Specialized Physical Medicine Interventions (Outpatient)

Policy number: MP 8.001

Effective date: 9/1/2026

Policy

NOTE: Effective 2/1/2013, Capital Blue Cross adopted InterQual guidelines for Physical Therapy services. This policy only applies, therefore, to the treatment of conditions not listed in the InterQual Outpatient Rehabilitation guidelines or to specific services listed in this policy which are not addressed in the InterQual guidelines.

Specialized Physical Medicine Treatments

Miscellaneous Electrical Stimulation Modalities

Note: There are several varieties of electrical stimulation modalities, many of which are not discussed in this policy but are appropriate in a physical medicine setting. Several of these are discussed in separate, specific policies. If a separate policy does exist, then the criteria for medical necessity in that policy supersede the guidelines in this policy (see cross references).

The following miscellaneous electrical stimulation modalities are considered investigational for all conditions as there is insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with these procedures:

• Horizontal Therapy (e.g., Hako-Med Machine)
• High Voltage Galvanic Stimulation (HVG)
• Pre-modulated Electrical Stimulation
• Electrical or electromagnetic stimulation for osteoarthritis, rheumatoid arthritis

Radiofrequency Therapy

Radiofrequency therapy for the treatment of wounds, edema or plantar fasciitis is considered investigational as there is insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with this procedure.

Dry Hydrotherapy

The use of dry hydrotherapy massagers for the treatment of chronic pain conditions is considered investigational as there is insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with this procedure.

Note: Coverage exclusions do not apply to members/groups whose benefits are subject to the terms mandated in the Pennsylvania Act 62 of 2008, Section 635.2, Autism Spectrum Disorders Coverage.

Cross-references:

• MP 2.005 Other Treatments of Hyperhidrosis
• MP 2.372 Occipital Nerve Stimulation
• MP 4.028 Wound and Burn Management and Specialized Treatment Centers
• MP 6.013 Pneumatic Compression Devices for Treatment of Lymphedema and Chronic Venous Insufficiency
• MP 6.020 Transcutaneous Electrical Nerve Stimulation
• MP 6.026 Durable Medical Equipment (DME) and Supplies
• MP 6.040 Cooling Devices Used in the Outpatient Setting
• MP 6.046 Threshold Electrical Stimulation as a Treatment of Motor Disorders
• MP 6.047 Interferential Current Stimulation
• MP 6.049 H-Wave Electrical Stimulation
• MP 6.050 Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
• MP 6.051 Neuromuscular and Functional Neuromuscular Electrical Stimulation

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to FEP Medical Policy Manual. The FEP Medical Policy Manual can be found at: FEP Medical Policy Manual.

Description/Background

Physical Medicine is therapeutic exercise used to treat and to prevent the onset or slowing the progression of conditions resulting from injury and disease. The interventions focus on increasing strength and endurance, improving ambulation, and assisting the patient to perform the basic activities of daily living. Treatment may include active and passive modalities using a variety of techniques based upon biomechanical and neurophysiological principles.

Miscellaneous electrical stimulation modalities include horizontal therapy (e.g., Hako-Med machine), high voltage galvanic stimulation (HVG) and pre-modulated electrical stimulation. Horizontal therapy is a type of electrotherapy used in the treatment of osteoarthritis, with low frequency, variable intensity stimulatory frequencies and non-stimulatory, medium frequency alternating current therapies. High voltage galvanic stimulation (HVG) uses high voltage, pulse stimulation that is purported to reduce local edema, relax muscle spasms, increase local blood circulation, maintain, or increase range of motion, prevent or retard disuse atrophy, conduct muscle re-education, and affect immediate post-surgical stimulation of calf muscles to prevent thrombosis. The High Voltage Galvanic Stimulator (Control Solutions, Inc.) received 501(k) clearance from U.S. Food and Drug Administration (FDA) in June 2004. Pre-modulated electrical stimulation uses an amplitude modulated waveform.

Electrical and electromagnetic stimulation are being investigated to improve functional status and to relieve pain related to osteoarthritis and rheumatoid arthritis that are unresponsive to other standard therapies. Noninvasive electrical stimulators generate a weak electrical current within the target site using pulsed electromagnetic fields, capacitive coupling, or combined magnetic fields. In capacitive coupling, small skin pads or electrodes are placed on either side of the knee or wrist. Electrical stimulation is provided by an electronic device that noninvasively delivers a subsensory low-voltage, monophasic electrical field to the target site of pain. Pulsed electromagnetic fields are delivered via treatment coils placed over the skin. Combined magnetic fields deliver a time-varying field by superimposing that field onto an additional static magnetic field.

In basic research studies, pulsed electrical stimulation has been shown to alter chondrocyte-related gene expression in vitro and to have regenerative effects in animal models of cartilage injury. It is proposed that the device treats the underlying cause of the disease by stimulating the joint tissue and improving the overall health of the joint and that it provides a slow-acting, but longer-lasting improvement in symptoms. Therefore, pulsed electrical stimulation is proposed to be similar to bone stimulation therapy for fracture nonunion.

Examples of marketed joint electrical stimulation devices include but are not limited to The BioniCare Bio-1000 Stimulator (VQ OrthoCare), the OrthoCor™ Active Knee System (OrthoCor Medical; acquired by Caerus Corp. in 2016), the SofPulse™ (also called Torino II, 912-M10, and Roma3™; Ivivi Health Sciences, renamed Amp Orthopedics), and the ActiPatch® (BioElectronics).

It is expected that the physical medicine portion of the treatment would only last for one to two weeks, 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. It was noted in recent literature that manual lymphedema therapy is effective when performed for one hour three times per week.

Direct Physical Therapy Access refers to a physical therapist that has a certificate of authorization to practice physical therapy without a physician’s referral. A certificate holder may treat a person without a referral as provided in the State Board Direct Access Regulations and Statute for up to 30 calendar days from the date of the first treatment. A physical therapist may not treat a person beyond 30 days from the date of the first treatment unless the person has obtained a referral from a licensed physician, dentist, or podiatrist. The date of the first treatment is the date the person is treated by any physical therapist treating without a referral.

A certificate holder may not treat a condition in any person which is a non-neurologic, non-muscular or non-skeletal condition or treat a person who has an acute cardiac or acute pulmonary condition unless the certificate holder has consulted with the person’s licensed physician, dentist or podiatrist regarding the person’s condition and the physical therapy treatment plan or has referred the person to a licensed physician, dentist or podiatrist for diagnosis and referral. The certificate of authorization shall be displayed by the certificate holder in a manner conspicuous to the public. The renewal of the certificate of authorization shall coincide with the renewal of the license of the licensee.

Dry hydrotherapy, also known as hydromassage or aquamassage, is a massage treatment modality that circulates streams of heated, pressurized water in a self-contained device such as a bed or chair. The individual remains clothed and dry as they sit or lie on top of a waterproof barrier containing rotating and pulsating interior jets. Purported benefits of dry hydrotherapy include alleviation of pain, increased blood circulation, improved range of motion, deep relaxation, and reduction of stress and anxiety. Use of dry hydrotherapy has also been suggested to reduce the need for other interventions, by combining the effects of traditional wet hydrotherapy, massage therapy, acupressure, heat therapy, soft tissue manipulation, and trigger point therapy without the need for additional health staff.

Specific physiological effects claimed on the Sidmar manufacturer site for its hydromassage tables include purported physiological effects stemming from application of radiant heat and massage. Purported physiological effects of radiant heat include analgesic, antispamodic, decongestive, sedative, and vasodilatory properties, leading to reduced pain, increased relaxation, enhanced capillary blood flow, decreased spasticity, tenderness, and spasm, and increased rates of healing. Purported benefits of massage include increased local blood supply, increased lymphatic drainage and reduction of swelling, muscle relaxation, prevention of adhesions and fibrosis, decreased tendency toward muscle atrophy, and pain reduction and increased ease of mobility.

Examples of currently marketed dry hydrotherapy devices include but may not be limited to HydroMassage branded (previously AquaMED) beds and loungers (JTL Enterprises Inc.), Massage Time Pro S10 or ComfortWave S10 branded hydromassage tables (Sidmar Manufacturing Inc.), and SolaJet® Dry-Hydrotherapy Systems. There is no FDA approval required for these devices, only 510(k) clearance.

Definitions

Basic activities of daily living include and are limited to walking in the home, eating, bathing, dressing, and homemaking.

Biomechanics is the application of mechanical forces to living organisms and the investigation of the effects of the interaction of force and the body or system.

Maintenance program is a therapy program that consists of activities that preserve the patient’s present level of function and prevents regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved or when no further progress is apparent or expected to occur.

Neurophysiological treatment approach involves various techniques used in sensorimotor rehabilitation that rely on voluntary and inhibition of muscle action through the reflex arc.

Sensorimotor therapy is therapy designed to enhance the integration of reflex phenomena and the emergence of voluntary motor behaviors concerned with posture and locomotion.

Vestibular rehabilitation is an alternative form of treatment involving specific exercises designed to (1) decrease dizziness; (2) increase balance function; (3) increase general activity levels. The exercise program is designed to promote central nervous system compensation for the inner ear deficits.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These policies are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the members’ benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Investigational when used for electrical stimulation of OA and RA; therefore, not covered:

Investigational when used for medical equipment associated with investigational procedures addressed in this policy; therefore, not covered:

Investigational when used for miscellaneous electrical stimulation modalities addressed in this policy; therefore, not covered:

Investigational when used for dry hydrotherapy; therefore, not covered:

Investigational when used for radiofrequency therapy for wounds, edema, or plantar fasciitis; therefore, not covered:

• Specific diagnosis coding does not apply to this policy.

References

1. APTA American Physical Therapy Association.
2. Mosby's Medical, Nursing and Allied Health Dictionary, 6th edition.
3. Pennsylvania Board of Physical Therapy – Rules and Regulations re: “Direct Access”.
4. Taber's Cyclopedic Medical Dictionary, 19th edition.
5. Ahmad ET. High-voltage pulsed galvanic stimulation: effect of treatment duration on healing of chronic pressure ulcers. Ann Burns Fire Disasters. 2008;21(3):124–128.
6. Ozcan J, Ward AR, Robertson VJ. A comparison of true and premodulated interferential currents. Arch Phys Med Rehabil. 2004;85:409-15.
7. DE Domenico GE, Strauss GR. Motor stimulation with interferential currents. Aust J Physiother. 1985;31(6):225–230. doi:10.1016/S0004-9514(14)60636-X
8. Sidmar. Healthcare Data. 2022.
9. HydroMassage. Featured Products. 2022.
10. Sidmar. Shop. 2022.
11. SolaJet. The SolaJet. 2021.
12. Washington State Department of Labor & Industries. AquaMED Technology Assessment. 1998;
13. Chiropractic Economics. AquaMED and HydroMassage announce brand integration. January 28, 2009.
14. HydroMassage. HydroMassage Benefits: Ways Water Massage Can Improve Wellness & Recovery. January 20, 2022.
15. National Institute for Health and Care Excellence (NICE). NICE guideline [NG65]. Spondyloarthritis in over 16s: diagnosis and management. February 28, 2017.
16. Saggini R, Carniel R, Coco V, Cancelli D, Iannieri M, Maccanti D. Gonarthrosis. Treatment with horizontal therapy electrotherapy. Multicenter study. Europa MedicaPhysica, September, 2004.
17. de Paula Gomes CAF, Politti F, de Souza Bacelar Pereira C, et al. Exercise program combined with electrophysical modalities in subjects with knee osteoarthritis: a randomised, placebo-controlled clinical trial. BMC Musculoskelet Disord. Apr 20 2020; 21(1): 258. PMID 32312265
18. Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guideline for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. Nov 2019; 27(11): 1578-1589. PMID 31278997
19. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res (Hoboken). Feb 2020; 72(2): 149-162. PMID 31908149
20. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken). Jul 2021; 73(7): 924-939. PMID 34101387
21. Li X, Zhang L, Gu S, et al. Comparative effectiveness of extracorporeal shock wave, ultrasound, low-level laser therapy, noninvasive neurostimulation, and pulsed radiofrequency treatment for treating plantar fasciitis: A systematic review and network meta-analysis. Medicine (Baltimore). 2018;97(43):e12819.