Click to Schedule Online Now!

Premera Blue Cross and 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.

The prior authorization is done through a 3rd party hired by Premera called eviCore.  The PA has to be done within 7 days after your 1st visit.   I take care of this process.  What it means is that I take the prescription and your plan details and plug them into eviCore's website and they will tell me how many sessions you can get for your massage therapy.  This ignores your plan benefits and the doctor's prescription.   What usually happens is that they approve an initial 4 sessions no matter what your condition is.  After the 4 sessions have been completed, I can sometimes request more sessions and they usually will approve 2-3 sessions depending on their computer system. 

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

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