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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.

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