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  • Humana Coverage Limitations: More of the Same

    Humana’s latest list of physical therapy services it won't cover may not have changed much, but that doesn't mean the limitations should continue, according to APTA. The association recently voiced its concerns over the ways the health insurer characterizes physical therapy, its imprecise terminology, and its continued noncoverage of aquatic physical therapy and group physical therapy.

    The APTA letter was sparked by the release of the latest updates to Humana's medical coverage policy, which has drawn attention in the physical therapy community because of a list of services it says it may not cover. That list includes aquatic therapy, group therapy sessions, sensory integration, community/work reintegration, and work hardening/conditioning.

    While disappointing for physical therapists (PTs) and their patients, the coverage limitations themselves aren't new, according to Alice Bell, PT, DPT, senior payment specialist at APTA. Bell was part of a payment and practice management staff team that reviewed the policy.

    "The latest update from Humana changed very little from the policy in place in 2017 and earlier," Bell said. "Noncoverage of aquatic therapy, group therapy, and work hardening dates back to at least 2014."

    Still, that doesn't mean the policy is acceptable, in APTA's view. Earlier this month, APTA sent a letter to Humana that specifically cites aquatic therapy and group therapy as services that should be covered.

    "Evidence demonstrates that for some patients the progression to land-based exercise and functional movement is effectively facilitated through the use of aquatic therapy," the letter states. When it comes to group therapy, APTA asserts that for certain conditions and patient populations, "the psychosocial benefits of peer support and group interaction can serve to enhance the therapeutic experience and impact," adding that it's distinct from group exercise in its integration into an overall skilled plan of care aimed at optimizing the effectiveness of therapy.

    The APTA letter also points out other areas in which Humana uses sloppy language or just plain gets it wrong. One example: Humana's description of exercise as a modality. "Modalities are passive interventions," the association reminds Humana. "Therapeutic exercise is an active aspect of therapy."

    APTA also describes Humana's statement that "[physical therapy] procedures in general include therapeutic exercises and joint mobilization" as an "extremely narrow" characterization of the profession.

    "Representing the interventions in such a limited way in the description of the practice fails to acknowledge the breadth and depth of the profession, the therapeutic benefit to the patient, and the services covered under the current policy," the letter states. "APTA would like to highlight that the core of skilled physical therapist practice lies in the evaluation, reevaluation, and implementation of therapeutic procedures."

    "Humana has taken some positive steps, particularly when it lifted prior authorization requirements for physical therapy earlier in the year," Bell said. "The latest coverage policy updates do not move any issues forward—or backward for that matter. That's why APTA will continue to advocate for changes that better serve patients."


    • The updated CDC opioid guidelines refer to exercise as a 'modality'. https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1er.pdf See page 19. I believe the term is being used as synonymous with the word intervention and does not imply it is inherently passive.

      Posted by Brendan Sullivan, PT, DPT, MSCS, CSCS on 2/28/2018 11:28 PM

    • Also, please note that Group according to the Medicare Policy manual the patients do not need to be doing the same activity. Humana is also denying group when used appropriately for Medicare replacement plans following Medicare guidance on use of Group when another patient is present in the outpatient setting. They are stating it is experimental

      Posted by Marjorie Ratliff, PT, MSA on 3/1/2018 10:17 AM

    • Humana dropping their pre-authorization looked like a step in the right direction, however they replaced it with denying claims on initial submission and asking for documentation on each visit- which is significantly slowing payment & is labor intensive. Although their policy regarding aquatic therapy is dated effective 3/1/18- they have been denying payment since the first of the year. Keep up the good fight and thanks for what you have done.

      Posted by Amanda Somers, PT, DPT on 3/1/2018 2:22 PM

    • Humana and United Healthcare typically lead the way in making life difficult for physical therapists. Don't expect that to change for the better. It will only get worse. Why do we put up with it? I consistently tell my patients that these are two of the worst insurance companies and I would NEVER have them as my personal health insurance companies. We need to take off the gloves and be more aggressive in how we counter these corporations.

      Posted by Brian Miller on 3/5/2018 8:09 PM

    • The non-payment for aquatic therapy is absurd. If all the talk is the opiod epidemic, seems the insurance companies would start denying more "drugs" and promoting more for physical therapy. There is closure when physical therapy is utilized appropriately.

      Posted by Patricia Kocich on 3/6/2018 10:49 AM

    • We have completely dropped Humana as an insurance that we are able to accept. They simply stopped paying on any of our claims, regardless of the "exactness" / thoroughness of our documentation.

      Posted by Donna Carver -> >FTc?N on 3/23/2018 4:58 PM

    • Humana PFFS members have had a physical therapy cap for years and recently 3 different customer service reps have told us that there no longer is a cap. Does anyone know if this is correct?

      Posted by LINDA KNOWLES on 7/12/2018 10:03 AM

    • Contacted Humana today to see if the physical therapy that my doctor wants me to undergo would be covered. After a lot of run around on both their web site and phone I could only get a quote for $40 covered by them at an in-house provider, but they wouldn't direct me to any in-house providers. When i asked them on what page of their new handbook I could find more information it was like I was asking them for the keys to the Vatican or something. I have finally had it with all insurance corporations and believe that they should be called what they really are professional ponzi scammers. I am now refusing all medical services and want to know why I can easily get a penile implant or ED drugs, but have to jump through hoops to get the medical recommendations that my doctor orders. It is time to hold all insurers responsible for the needless deaths they cause every day by refusing the services that we are forced to pay for.

      Posted by John on 5/24/2019 3:00 PM

    • I would like to know if a knee relacement is covered under humana

      Posted by Tracy L Wrieden on 6/17/2019 3:21 PM

    • Looking for a in patient health and rehabilitation center for my sister. ASAP

      Posted by Tanya on 7/11/2019 2:14 PM

    • Humana policy states that PT needs to be ordered by a physician and also they need a signed PoC for every patient. Does Direct Access trump this requirement? Meaning, if a patient is direct access- no prescription is needed and signed PoC is obtained as indicated per the state law.. any experience with denials due to lack of prescription?

      Posted by Palak Shah on 9/25/2019 3:55 PM

    • Anyone experiencing denials by Humana due to lack of prescription from physicians? The PT policy indicates that PT should be ordered by a physician and also all written POCs have to be signed. If a Humana patient is direct access, is it ok to follow Direct access rules instead?

      Posted by Palak Shah -> AJXc=I on 9/25/2019 5:04 PM

    • Does this include Medicare Advantage plans? Wouldn't a plan need to stay within the guidelines of Original Medicare? louisvillemedicareplans.com

      Posted by Laquesha Harris on 10/26/2019 10:47 PM

    • I’m supposed to have PT to help be able to swallow again. I’m concerned about the cost and actual approval from Humana. From what I’m ready Humana doesn’t cover a lot and then difficult time getting pay out of them. I need this therapy but can’t afford it. What can be done?

      Posted by Charles Thomas on 5/19/2020 12:58 PM

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