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Physical therapists who bill through Anthem: Depending on the state in which you're practicing (and/or the state in which your patient resides), you could be operating under new utilization management guidance that lays out what is and isn't considered medically necessary. The new guidelines, which include a list of exclusions to so-called "adjunctive treatments," affects Medicare Advantage, Medicaid, and commercial insurance in various states.

Now's the time to get familiar with it.

The guidance was produced by American Imaging Management Specialty Health, or AIM, a subsidiary of Anthem that serves as Anthem's UM arm for various programs in numerous states including:

  • Medicare Advantage: California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire, New Mexico, New York, Ohio, Tennessee, Texas, Washington, and Wisconsin.
  • Medicaid: Indiana, New York, Wisconsin, and New Mexico.
  • Anthem commercial policies: Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, New Hampshire, Nevada, New York, Ohio, and Wisconsin.

The AIM Clinical Appropriateness Guidelines took effect on Dec. 1, 2020, and all AIM decisions made after Dec. 6 have been based on the new guidance. It's a change that could impact large numbers of PTs, occupational therapists, and speech-language pathologists across the country.

Pay Special Attention to the Alternative and Adjunctive Treatment Section
The guidelines have sections for physical therapy, occupational therapy, and speech-language pathology, all which include general information, clinical indications, and exclusions —treatments not considered medically necessary.

In addition, a separate section focuses on "adjunctive and alternative treatments" in physical and occupational therapy (pp. 27-33). APTA recommends that PTs pay particular attention to this section, because that's where AIM identifies treatments that it defines as "not medically necessary in all clinical scenarios." These include electrical stimulation (unattended), instrumented motion analysis, mechanical traction, iontophoresis, vasopneumatic compression, and more. Dry needling is considered medically necessary for certain types of pain listed in the guide, but it’s ruled out for "hand or wrist conditions such as carpal tunnel syndrome as well as when underlying psychological/cognitive mechanisms of pain are present."

More on Utilization Management
The use of third-party vendors to provide prior authorization and utilization management services is a growing trend that presents challenges — and some opportunities — for therapists. APTA has been working with insurers and UM vendors to establish procedures that ensure the PT's ability to exercise clinical judgment, provide timely patient access to medically necessary services, and offer streamlined administrative processes. The association's Utilization Management and Utilization Review webpage provides insights and links to template letters that providers and their patients can use when access to medically necessary care is denied, impeded, or delayed. Questions? Contact advocacy@apta.org.


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