CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Dry Hydrotherapy for Chronic Pain Conditions

This policy governs coverage determinations for use of dry hydrotherapy (also called hydromassage or aquamassage) to treat chronic pain conditions for BCBSRI members, including Medicare Advantage and commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDry Hydrotherapy for Chronic Pain Conditions

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 11, 2022

Next Review DateN/A

Key ActionDo not bill for dry hydrotherapy as covered for Medicare Advantage; if submitting claims, use unlisted modality code 97039 and include type and time.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredMedicare Advantage coverage stance

Not medically necessaryCommercial products coverage stance

97039Unlisted CPT

FDA Class IDevice classification

Coverage Determinations and Criteria

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Coverage determinations

Coverage stance by product

Medicare Advantage: Use of dry hydrotherapy massagers for the treatment of chronic pain conditions is not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.

Commercial Products: Use of dry hydrotherapy massagers for the treatment of chronic pain conditions is not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.

Dry hydrotherapy devices circulate heated, pressurized water within a self-contained bed or chair and deliver massage through a waterproof barrier while the individual remains clothed and dry. Dry hydrotherapy does not involve water immersion and therefore is distinct from immersion hydromassage baths or powered sitz baths, which are different device types and have separate FDA product codes.

For commercial products, the use of dry hydrotherapy massagers to treat chronic pain is considered not medically necessary. The policy finds the evidence insufficient to determine the effects of the technology on health outcomes and therefore does not support coverage for this indication.

Provider Requirements and Billing Guidance

Prior Authorization

Prior authorization — No prior authorization applicable; coverage not provided or considered not medically necessary as specified.

Note

Provider Action

Provider action — Inventory: Medical criteria not applicable for this service.

Billing Rule

Billing Documentation

Billing documentation — Submit claims with the unlisted modality code 97039 and specify the type of service and time. If constant attendance applies, indicate that on the claim.

Use CPT 97039 (Unlisted modality) and specify type and time
Indicate constant attendance when applicable

Denial Risk

Coverage Denial Risk

Coverage denial risk — For Medicare Advantage plans, claims are not covered. For commercial products, the service is considered not medically necessary and will be denied.

Medicare Advantage: Not covered
Commercial: Not medically necessary

Background and Clinical Context

Dry hydrotherapy (also called hydromassage or aquamassage) is a non-immersion massage modality delivered via a self-contained device such as a bed or chair that circulates streams of heated, pressurized water. The person remains clothed and dry while receiving treatment because rotating and pulsating interior jets act through a waterproof barrier. Manufacturers and proponents describe benefits including pain relief, increased circulation, improved range of motion, relaxation, and potential reduction in the need for other interventions by combining features of wet hydrotherapy, massage, heat therapy, and soft-tissue techniques.

Definitions and Regulatory Status

Device description — Dry hydrotherapy (hydromassage/aquamassage)

Device typeSelf-contained bed or chair that circulates heated, pressurized water through interior jets while the individual remains clothed and dry on top of a waterproof barrier

FunctionProvides massage via rotating and pulsating interior jets (streams of heated, pressurized water) contained within the device

Patient experienceIndividual sits or lies on the waterproof barrier and remains clothed and dry during treatment

Purported benefitsAlleviation of pain, increased circulation, improved range of motion, relaxation, and reduced need for other interventions

Distinct fromDoes not involve water immersion and is different from immersion hydromassage baths or powered sitz baths

FDA classification — Dry hydrotherapy devices

FDA classificationClass I therapeutic massager (FDA Product Code: ISA; Sec. 890.5660)

Regulatory implicationClass I devices are exempt from 510(k) requirements and do not require submission of clinical efficacy data

Intended use descriptionElectrically powered device intended to relieve minor muscle aches and pains

Marketing requirementNotification to FDA prior to marketing is required (no 510(k) submission)