Premera Blue Cross and Massage Therapy Benefits

I accept Regence Blue Shield and Premera Blue Cross. Both Companies require that you have a pain condition AND a loss of function. 

That means that you MUST also  have some degree of not being
able to sit, stand, walk, stair climb, lift, work, personal care, drive, or sleep because of or in addition to your pain.

Each has different requirements and benefits that you will need to know and be responsible for. Please read more at these pages: Regence Blue Shield and Premera Blue Cross

ALL Plans require that massage therapy be medically necessary and each plan has their own specific definition of what that means. Check your policy.  Here are some sample definitions of medical necessity.

All insurance claims must have a prescription from your doctor with a diagnosis in order to be processed, no matter what the insurance company says. A prescription is different from a referral.  Some plans will say that you do not need a referral, but you still will need a prescription.  A prescription will provide a diagnosis code and a treatment plan stating the number of sessions the doctor is prescribing and the duration. (Example: 1x a week for 6 weeks)

You will be allowed 6 sessions to be completed without prior-authorization. After that, your insurance requires that I obtain a prior-authorization from a company they have hired called eviCore, before completing more sessions.

Insurance will only cover massage if there is an injury or condition that makes it medically necessary to get a massage.  Medically necessary massage therapy is done once or twice a week depending on the prescription and condition.

It does not cover massage just for stress, anxiety or depression.

It does not cover maintenance or preventative massage. Each insurance company has their own definition of maintenance massage.  I define it as massage therapy done once a month, every three weeks or every other week.  Massage must be done (time allowing) once a week for massage to give the best benefits. I have to show that there is improvement in your condition.

It does not cover soreness due to exercise.

Some of the conditions that massage can help and that your health insurance will cover are:


Use this handy insurance verification form (PDF) if you call your insurance to investigate your massage therapy benefits.


Massage therapy may be covered by your Premera Blue Cross plan when your condition is considered to be medically necessary.

All plans require a prescription from a doctor.  The insurance company representatives will often say that it is not required.  As a massage therapist, I am not allowed to diagnose conditions so a diagnosis needs to come from a doctor in order for  your sessions to be covered by insurance.

As of June 7, 2018, prior authorization is no longer required for your first 6 sessions.  After your 6 sessions are completed, more sessions can be requested as required through eviCore, the third party prior authorization company.  They usually will allow a few more sessions depending on your condition.  It does not matter what your doctor has prescribed.

What this means is that even though your insurance may allow 16 sessions and your doctor prescribes say 10 sessions or even the full 16 sessions, you get 4-6 sessions. 

Amazon.com employees and Microsoft employees are exempt from the prior authorization process, but a prescription is still required.

Premera Blue Cross Medical Necessity Definitions for massage therapy

Massage therapy must meet medical necessity directives outlined by your health insurance plan.  Below are the policies for Premera Plans.  Check your own plan for further confirmation.

Premera’s Medical Policies Bulletin states: 

https://www.premera.com/medicalpolicies/8.03.502.pdf (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 thetherapy 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