CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Dry Hydrotherapy (Hydromassage/Aquamassage) Coverage Criteria

Policy governing coverage and medical necessity determination for dry hydrotherapy (self-contained hydromassage devices) for Blue Cross Blue Shield - Rhode Island members; applies to Medicare Advantage and commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDry Hydrotherapy (Hydromassage/Aquamassage) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 11, 2022

Next Review DateJul 1, 202618d

Key ActionFor claims, submit using unlisted modality code 97039 and specify type and time if constant attendance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not medically necessaryCommercial stance

Not coveredMedicare Advantage stance

97039Claims code

FDA class IRegulatory

Coverage Criteria

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

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

Dry hydrotherapy is provided using a self-contained device (for example, a bed, lounger, or chair) that circulates heated, pressurized water beneath a waterproof barrier so the individual remains clothed and dry. Dry hydrotherapy does not involve water immersion and is distinct from immersion hydromassage baths or powered sitz baths; the patient is not immersed in water during treatment.

For Commercial products, the use of dry hydrotherapy massagers for the treatment of chronic pain conditions is considered not medically necessary. This determination is based on an insufficient evidence base to demonstrate that dry hydrotherapy improves relevant health outcomes (symptoms, function, quality of life, medication use, or resource utilization) for chronic musculoskeletal, neuropathic, or mixed pain conditions.

Provider Actions & Billing Guidance

Prior Authorization

Prior Authorization: Not applicable.

Note

Benefit Variation Note

Benefit Variation Note: Benefits may vary by contract. Refer to the Evidence of Coverage or Subscriber Agreement for applicable benefits, including any determination of not medically necessary or not covered.

Billing Rule

Claims Filing

Claims Filing: There is no specific code for this service. Submit claims using the unlisted modality code 97039 (Unlisted modality) and specify the type of service and time if billed as constant attendance.

Use code 97039 — Unlisted modality (specify type and time if constant attendance)

Denial Risk

Coverage Denial Risk

Coverage Denial Risk: Dry hydrotherapy massagers for treatment of chronic pain are considered not covered / not medically necessary for Commercial Products and not covered for Medicare Advantage Plans due to insufficient evidence. Claims are at high risk for denial.

Medicare Advantage Plans: not covered
Commercial Products: not medically necessary

Background

Dry hydrotherapy devices deliver streams of heated, pressurized water within a self-contained bed, lounger, or chair. The water is circulated beneath a waterproof barrier so the user remains clothed and dry while massage-like forces are applied through the barrier. Devices are typically electrically powered, self-contained systems designed to provide localized, massage-like effects without immersing the patient in water (examples include HydroMassage beds and loungers, hydromassage tables, and SolaJet® Dry‑Hydrotherapy Systems).

Definitions & Regulatory Classification

Dry hydrotherapy (hydromassage/aquamassage) — definition

DefinitionDry hydrotherapy (hydromassage/aquamassage) is a modality using a self-contained bed or chair that circulates heated, pressurized water beneath a waterproof barrier so the individual remains clothed and dry while receiving massage-like effects from rotating and pulsating interior jets.

Delivery methodHeated, pressurized water streams circulate within the device beneath a waterproof barrier; the patient sits or lies on top of the barrier and remains dry.

Purported benefitsAlleviation of pain, increased blood circulation, improved range of motion, deep relaxation, reduction of stress/anxiety, and potential reduction in need for other interventions.

Mechanisms describedCombines effects attributed to wet hydrotherapy, massage, heat therapy, soft tissue manipulation, acupressure, and trigger point therapy without immersion or additional health staff.

Regulatory classification — FDA class I therapeutic massager

FDA classificationClass I therapeutic massager — electrically powered device intended to relieve minor muscle aches and pains.

510(k) requirementClass I devices are exempt from 510(k) requirements; they do not require submission of clinical efficacy data but do require notification to FDA prior to marketing.

Regulatory noteClassification applies to dry hydrotherapy devices; these are distinct from immersion hydromassage baths or powered sitz baths.

Examples of marketed devicesIncludes HydroMassage beds and loungers (WellnessSpace Brands), Pro S10 or ComfortWave S10 hydromassage tables (Sidmar), and SolaJet® Dry-Hydrotherapy Systems.