CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy | Dry Hydrotherapy for Chronic Pain Conditions

Defines coverage position for dry hydrotherapy devices (self-contained hydromassage beds/chairs/tables) for treatment of chronic pain conditions for Medicare Advantage and commercial products, including coding guidance and regulatory background.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy | Dry Hydrotherapy for Chronic Pain Conditions

Policy CodePolicy N/A

Change TypeClarified coverage stance (no material change)

Effective DateNov 1, 2022

Next Review Date

Key ActionFile claims for dry hydrotherapy using CPT 97039 and document services and obtain member agreement in writing if charging a member when the service is non-covered.

SourceLink

POLICY UPDATE CHANGES

Policy states dry hydrotherapy is not covered for Medicare Advantage and not medically necessary for commercial products due to insufficient evidence.

0Covered Indications

1Unlisted CPT code required

2Payer types addressed

Coverage Summary

Dry hydrotherapy (hydromassage/aquamassage) for chronic pain is not covered for Medicare Advantage Plans and is not medically necessary for Commercial products due to insufficient evidence to determine effects on health outcomes. Effective: 11|01|2022; Last review: 07|20|2022.

Medical Necessity / Coverage Determinations

Coverage determinations

Coverage statements for dry hydrotherapy:

ALL of the following

Medicare Advantage Plans: The 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: The 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.
Medical criteria: Not applicable.
Prior authorization: Not applicable.

Provider Actions & Billing

Billing Rule

Use unlisted modality code

Claims for dry hydrotherapy should be filed using CPT 97039 (Unlisted modality); specify type and time if constant attendance as required by the code.

97039

Documentation Required

Document medical necessity rationale if provided despite noncoverage

Although the policy states the service is not covered or not medically necessary, benefits and eligibility are determined by the member's subscriber agreement; document services and obtain the member's written agreement in advance if charging the member for non-covered services.

Background & Regulatory Notes

Dry hydrotherapy uses heated, pressurized water circulated inside a self-contained device (bed, chair, or table) so the individual remains clothed and dry while receiving massage from rotating and pulsating interior jets. Devices are classified by the FDA as Class I therapeutic massagers (Product Code ISA) and are exempt from 510(k) requirements. Claimed benefits include pain relief, increased circulation, improved range of motion, relaxation, and reduction in need for other interventions, but the evidence is insufficient to determine meaningful health outcomes.

Evidence / Definition

Regulatory classificationFDA class I therapeutic massager (Product Code ISA; Sec. 890.5660)

DefinitionA massage modality that circulates heated, pressurized water in a self-contained device such as a bed or chair; the individual remains clothed and dry on top of a waterproof barrier containing rotating and pulsating interior jets.

Revision History

2022-11-01policy_effective_date

Policy effective date; coverage stance: dry hydrotherapy massagers not covered for Medicare Advantage and not medically necessary for Commercial products due to insufficient evidence. Medical criteria and prior authorization are not applicable.

2022-07-20policy_last_review

Policy last reviewed; reaffirmed coverage determinations that evidence is insufficient to determine effects on health outcomes for chronic pain.

2022-11-01clarificationLatest

Clarified that there are no clinical criteria or prior authorization requirements applicable; policy states service is not covered/not medically necessary because evidence is insufficient. This clarification is non-material.

billing_guidanceLatest

Claims must be filed with unlisted modality code 97039 (Unlisted modality; specify type and time if constant attendance).

regulatory_noteLatest

Devices are FDA class I therapeutic massagers (Product Code ISA; Sec. 890.5660) and are exempt from 510(k) requirements.