Understanding Prior Authorizations : Regence Blue Shield

Most Regence Blue Shield Plans require prior authorizations for massage therapy services. The prior authorization process means that your massage therapist will have to go through a third party that has been hired by the insurance companies called eviCore to request massage therapy sessions. Just having a prescription/referral from your physician is not enough! Prior authorizations have to be completed and approved within 7 days after your first visit in order to be paid by your insurance. They can also be done in advance of your session. eviCore bases their decisions on what evidence there is for medically needed care for various conditions. They have everything outlined in their clinical practices guidelines. (PDF)

First your care must be “medically necessary”. Each insurance company has their own definition of medical necessity.

Regence Blue Shield from their prior authorization guide (PDF) (Accessed 05/10/2017):

Medically necessary services

Medically necessary services are defined as a health care service or supply that a physician or other health care provider exercising prudent clinical judgment would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

●In accordance with generally accepted standards of medical practice

●Clinically appropriate, in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease

●Not primarily for the convenience of the patient, facility, physician or other health care provider, and not more costly than an alternative service or sequence of services or supplies at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease

Generally accepted standards of medical practice refers to standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the medical community. This includes Physician Specialty Society recommendations, the views of physicians and other health care professionals practicing in relevant clinical areas and other relevant factors.

The Regence Blue Shield Administration Manual has further details and clarification:

Licensed Massage Therapists (LMPs) Billing guidelines

For care to be covered under the member’s benefit, a physician must diagnose a medical condition, which has resulted in functional loss, for which rehabilitation therapy is prescribed. The LMP will be reimbursed for services currently covered under the member’s rehabilitation or neurodevelopmental benefit. In addition to any prescription and/or required referral, coverage for the services of a LMP is subject to applicable member contract limitations. When the treating LMP submits a claim, it is not necessary to include the patient’s prescription. We do require the prescription to be on file in your office.

Most products cover services performed by a LMP under the outpatient rehabilitation benefit.

Therefore, these services are subject to the outpatient rehabilitation benefit contract requirements and limitations.

When billing for massage therapy services, please use the current appropriate CPT codes for all services rendered. Additional billing information is listed below:

•Units of service must be included on the claim

•Chiropractic manipulation codes are only payable to chiropractors.

•Osteopathic manipulation codes are only payable to Dos and NDs in the state of Washington.

•CPT codes, such as E&M codes, are not payable to physical, occupational, speech or licensed massage practitioners.

•A total of four units of modalities/procedures per date of service are accepted.

Maintenance therapy

Maintenance therapy means a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. Once the maximum therapeutic benefit has been achieved for a given condition, any additional therapy provided is considered maintenance therapy.

Note: Most products exclude coverage for maintenance therapy.

Prior Authorization does not mean that coverage is guaranteed. Payment by the insurance company is based on your plan benefits and available benefits.

What this means for you.

A prescription from your doctor is required for all massage therapy services no matter what your insurance company says on the phone. Many service representatives are unaware of this and may tell you that it is not needed. The key to getting the answer right is to ask the service representative the right question, “is a diagnosis code needed to bill and pay the massage therapist”? They will say yes, and since making a diagnosis is out of the scope of practice for a massage therapist, the codes MUST come from a provider who can diagnose

Functional loss means that you have a loss of function in some body area like... you can’t turn your head from neck pain, can’t raise your arm from shoulder pain, can’t sit or walk for limited times, things like that.

The prior authorization process will usually allow for 4 sessions of massage therapy to be done within a specific amount of time which is currently one month. I can get an extension of that time limit if we are unable to complete your sessions in the allotted time. After the 4 sessions have been completed, I may be able to get 2-3 more sessions with an additional request depending on your functional condition. This is the same for most conditions whether you just pulled a muscle or you fell down a ski slope.

Coverage is only for conditions where you have a loss of function, meaning you can’t complete some part of your regular daily activities.

Many massage therapists have been providing massage that is not medically necessary which is part of the reason for the insurance companies cracking down and requiring prior authorizations.

What you can do.

Many plans have been sold to companies/individuals without specific indications that prior authorizations are needed. The Office of the Insurance Commissioner (OIC) would love to know about this. If you also received information over the phone that a prescription was not needed or any other incorrect information about your plan and benefits, the OIC would be interested in knowing that too . You can personally file a complaint with the OIC at

Also contact your HR person or whoever purchases health insurance for your company and have them contact the OIC.

The OIC is most interested in whether or not there has been a delay in your care because of the prior authorization process and even more interested on whether or not more pain medications were needed by you because of this delay in care.

Understanding Prior Authorizations: Premera Blue Cross

Many Premera Blue Cross Plans require prior authorization through a company called eviCore to determine medical necessity based on evidence guidelines.

Premera’s Medical Policies Bulletin states:

(Accessed 05/10/2017)

Physical medicine and rehabilitation —physical therapy (PM&R –PT), including medical massage therapy services —may be considered medically necessary when ALL of the following criteria are met:

●The patient has a documented condition causing physical functional impairment, or disability due to disease, illness, injury, surgery or physical congenital anomaly that interferes with activities of daily living (ADLs). AND

●The patient has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time based on specific diagnosis-related treatment/therapy goals AND

●Due to the physical condition of the patient, the complexity and sophistication of the therapy and the therapeutic modalities used the judgment, knowledge, and skills of a qualified PM&R-PT or medical massage therapy provider are required.

●A qualified provider is one who is licensed where required and performs within the scope of licensure

AND

●PM&R PT and/or medical massage therapy services provide specific, effective, and reasonable treatment for the member’s diagnosis and physical condition consistent with a detailed plan of care

●PM&R PT and/or medical massage therapy services must be described using standard and generally accepted medical/physical/massage therapy/rehabilitation terminology. The terminology should include objective measurements and standardized tests for strength, motion, functional levels and pain. The plan should include training for self management for the condition(s) under treatment. Services provided that are not part of a therapy plan of care, or are provided by unqualified staff are not covered.

Medical massage therapy

Medical massage therapy may be considered medically necessary as the only therapeutic intervention when ALL of the above criteria for physical medicine and rehabilitation —physical therapy (PM&R –PT)are met

AND

The diagnosis specific prescription, from the attending clinician with prescribing authority, stating the number of medical massage therapy visits is retained in the member’s massage therapy medical record.

AND

The diagnosis-specific plan of care, approved by the attending clinician with prescribing authority, is retained in the member’s massage therapy medical record

Premera’s Medical Policies Disclaimer: Premera’s medical policy should be used as a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts these policies after careful review of published and peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is dynamic, the Company reserves the right to review and update policies as appropriate. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.

Members and their providers will need to consult the member’s benefit plan to determine if there is any exclusion or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered for a particular member. The member’s benefit plan determines coverage. Some plans exclude coverage for services or supplies that are considered medically necessary.)

What this means for you.

A prescription from your doctor is required for all massage therapy services no matter what your insurance company says on the phone. Many service representatives are unaware of this and may tell you that it is not needed. The key to getting the answer right is to ask the service representative the right question, “a diagnosis code needed to bill and pay the massage therapist?” They will say yes as it needs to be medically necessary which means massage therapists require a prescription from a physician as making a diagnosis is out of the scope of practice for a massage therapist.

Coverage is only for conditions where you have a loss of function, meaning you can’t complete some part of your regular daily activities.

Many massage therapists have been providing massage that is not medically necessary which is part of the reason for the insurance companies cracking down and requiring prior authorizations.

What you can do.

Also contact your HR person or whoever purchases health insurance for your company and have them contact the OIC.

eviCore’s Clinical Guidelines

Covered Services and Exclusions

Massage

Therapy

Covered Services

Massage Therapy for injury or illness for which massage has a therapeutic effect. Coverage is provided for up to a 60 minute session per visit when rendered by a participating massage therapist. Covered Services include but are not limited to acupressure, deep tissue massage, or as allowed by the massage therapists license.

Massage Therapy is considered medically necessary when all of the following circumstances have been met:

♣Significant lasting therapeutic benefits lead towards a resolution of the member’s subjective complaints

♣Functional limitations have improved significantly as a result of massage therapy treatment. Treatment is safe and effective and is not replacing or delaying other necessary medical care

♣Patient should have at least one (1) Functional Limitation as follows:

●Sitting

●Standing

●Walking

●Stair climbing

●Lifting

●Working

●Personal care (washing, dressing, etc.)

●Driving

●Sleeping

♣Patient should have at least one Subjective Complaint, as follows:

●Neck pain

●Shoulder pain

●Upper arm pain

●Forearm pain

●Wrist/hand pain

●Upper/mid back pain

●Low back pain

●Hip pain

●Upper leg pain

●Lower leg pain

●Ankle/foot pain

Massage Therapy Coverage Exclusions

Any manipulative techniques or procedures which are not generally accepted in a majority of states’ Massage Therapy licensing boards. Massage therapy supplies including but not limited to lotions.

The following are not covered under the plan:

♣Services provided by a non-participating practitioner, except for emergencies, or as authorized by eviCore healthcare

♣Services provided outside of the health plan’s service area, except for emergencies

♣Services that are not pre-authorized, except for initial visits or emergencies

♣Services incurred prior to the beginning or after the end of coverage

♣Services that exceed the combined maximum covered visits for the benefit year

♣Charges incurred for missed appointments

♣Educational programs

♣Services for conditions arising out of employment, including self-employment or covered under any workers’ compensation act or law

♣Services for any bodily injury arising from or sustained in an automobile accident that is covered under an automobile insurance policy

♣Charges for which the member is not legally required to pay

♣Services rendered by a person who ordinarily resides in the member’s home or who is related to the member by marriage or blood

Specific Services that are Limited or Excluded

♣Services for preventive, maintenance, or wellness care

♣Experimental or investigational services

♣Services not medically necessary as determined by eviCore healthcare

♣Vocational, stroke, or long-term rehabilitation

♣Hypnotherapy, behavior training, sleep therapy, or biofeedback

♣Treatment primarily for purposes of convenience

♣Thermography, hair analysis, heavy metal screening, or mineral studies

♣Transportation costs, including ambulance charges

♣Inpatient services

♣Advanced diagnostic services, such as MRI, CT, EMG, SEMG,

and NCV

♣Drugs, vitamins, nutritional supplements, or herbs

♣X-rays of any kind

♣Services related to menstrual cramps

♣Services related to addiction, including smoking cessation

♣Services related to the treatment of infertility

♣Services for any condition with minimal pain levels and/or functional deficits that can be self managed