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 laws around prior authorization allow you to get 6 sessions of massage without having a prior authorization from Premera. After your 6 sessions are completed, a prior authorization is required to receive more sessions . 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 and a few other companies are exempt from the prior authorization process, but a prescription is still required.
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 12/15/2019)
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.
The diagnosis-specific plan of care, approved by the attending clinician with prescribing authority, is retained in the member’s massage therapy medical record. Progress Report documentation describes the following:
oThe patient has at least one functional limitation (such as sitting, standing, walking, stair climbing, lifting, working, personal care, driving, or sleeping).
oThe patient has at least one subjective complaint (such as neck, shoulder, arm, wrist/hand, back, hip, leg, ankle/foot pain).
oTreatment frequency should be commensurate with severity of the chief complaint, natural history of the condition, and expectation for improvement.
▪When improvements in the patient’s subjective and objective findings are demonstrated-continued treatment with decreased frequency is appropriate.
▪Progress may be documented by increases in functional capacity and increasingly longer durations of pain relief.Physical Medicine and Rehabilitation: Physical Therapy (PM&R-PT) and medical massage therapy is considered not medically necessary when criteria are not met.
Maintenance massage therapy is not covered by insurance. Here is the Premera Blue Cross definition of Maintenance Massage:
"Maintenance therapy program:
A maintenance therapy program consists of activities that preserve the patient’s present level of function and prevent regression of that function rather than provide immediate corrective benefit. Maintenance begins when the therapeutic goals of the Plan of Care have been achieved, or when no additional functional progress is apparent or expected to occur. This may apply to patients with chronic and stable conditions where skilled supervision is no longer required and clinical improvement is not expected. The specialized knowledge and judgment of a qualified provider may be required to establish a maintenance program; however, the continuation of PM&R-PT and/or medical massage therapy services to maintain a level of function are not covered.Examples of maintenance therapy may include, but are not limited to:•Additional PM&R-PT and/or medical massage therapy services when the patient’s chronic medical condition has reached maximum functional improvement•PM&R-PT and/or massage therapy services that enhance performance beyond what is needed to accomplish routine functional tasks •Passive stretching exercises that maintains range of motion and are performed by non-skilled personnel
•A general home exercise program that is not focused on the identified impairments or functional limitations"
If you want Maintenance Massage Therapy you will have to pay cash for your sessions. Your FSA or HSA may cover the fees. You should also ask your employer to have the plans changed so that it is covered.
Massage therapy is used to reduce pain and increase range of motion along with increasing function. Coming in once a week is usually required to get the full effects. I will work with you for 4 to 6 sessions at the most and see where you are at. If you have found your condition has improved, you will end your sessions. You can come once a month or once every few months after that and pay cash for your sessions.
If your condition has not shown improvement, I will send you back to your doctor for more testing. If you get some improvement but not all, I may be able to request more sessions and get prior authorization if required.
If a new condition arises, you will need a new prescription. It is considered to be a "new episode" of care as defined by the laws (RCW 48.43.016 Prior authorization standards and criteria—Health carrier requirements—Definitions.) around prior authorization.
(a) "New episode of care" means treatment for a new or recurrent condition for which the enrollee has not been treated by the provider within the previous ninety days and is not currently undergoing any active treatment.
If the original condition that you were referred to has come back after 90 days, it may be covered by your health insurance but again a new presciption is needed.