CurrentCapital BluecrossPolicy MP 8.001

Investigational Physical Medicine and Specialized Physical Medicine Interventions (Outpatient)

Defines Capital Blue Cross's policy that specific outpatient physical medicine interventions and modalities (various electrical stimulation modalities, radiofrequency therapy for wounds/edema/plantar fasciitis, dry hydrotherapy, and associated DME/procedure codes) are considered investigational and therefore not covered for all conditions except where InterQual outpatient rehabilitation guidelines or separate policies apply.

Policy Summary

PayerCapital Bluecross

PolicyInvestigational Physical Medicine and Specialized Physical Medicine Interventions (Outpatient)

Policy CodePolicy MP 8.001

Change TypeMaterial coding and investigational scope updates (2024–2025)

Effective Date11/1/2025

Next Review Date

Key ActionConfirm whether the patient's condition is listed in InterQual Outpatient Rehabilitation guidelines; if it is, follow InterQual criteria. If a separate Capital Blue Cross policy exists for the modality, follow that policy's criteria.

SourceLink

POLICY UPDATE CHANGES

09/09/2025 Administrative Update: Removed Benefit Variations Section and updated Disclaimer.

05/08/2025 Minor Review: Removed 'any other condition' from investigational statement for electrical stimulation for OA and RA; moved code 97039 to investigational for dry hydrotherapy; added 28899, 24999, and 27599 as investigational to represent radiofrequency therapies.

08/06/2024 Minor Review: Added electrical stimulation for osteoarthritis, rheumatoid arthritis, or any other condition as investigational; added code E0762 as investigational.

5Investigational interventions listed

Coverage Summary

Scope: This policy defines Capital Blue Cross' stance that specified outpatient physical medicine interventions — including miscellaneous electrical stimulation modalities (e.g., Horizontal Therapy/Hako‑Med, High Voltage Galvanic Stimulation, pre‑modulated electrical stimulation, and electrical/electromagnetic stimulation for osteoarthritis and rheumatoid arthritis), radiofrequency therapy for wounds/edema/plantar fasciitis, dry hydrotherapy (hydromassage/aquamassage), and associated durable medical equipment/procedure codes — are considered investigational and therefore not covered for the indications listed in the policy, except where InterQual Outpatient Rehabilitation guidelines or a separate Capital Blue Cross policy apply.

Overview: The policy lists specific codes as investigational when used for the investigational indications (e.g., E0762 for electrical stimulation of OA/RA; G0283, 97014, 97032 for miscellaneous electrical stimulation modalities; 97039 for dry hydrotherapy; 24999, 27599, 28899 for radiofrequency therapies; and E1399 for DME associated with investigational procedures) and states claims for these listed modalities and codes are considered not covered when used for the investigational indications. Effective date: 11/01/2025. Last review: 09/09/2025. Status: CURRENT.

Policy metadata

Policy numberMP 8.001

Policy titleInvestigational Physical Medicine and Specialized Physical Medicine Interventions (Outpatient)

PayerCapital Blue Cross

Effective date11/1/2025

Last review09/09/2025

Has material changeYes (policy history and coding/clinical updates noted)

Applicability / Exceptions: This policy applies only to conditions not addressed in the InterQual Outpatient Rehabilitation guidelines and to specific services listed in this policy which are not covered by InterQual. If a separate Capital Blue Cross policy exists for a given modality, that separate policy's criteria supersede this policy's criteria.

Coverage exclusions set forth in this policy do not apply to members/groups whose benefits are subject to Pennsylvania Act 62 of 2008, Section 635.2 (Autism Spectrum Disorders Coverage).

Cross‑reference guidance: See related Capital Blue Cross policies (examples listed in cross‑references) which may supersede or provide additional criteria for specific modalities; claims for the listed investigational modalities and associated codes should be processed as not covered when used for the investigational indications in this policy unless superseded by InterQual or a separate Capital Blue Cross policy.

Medical‑Necessity / Investigational Criteria

Coding — Investigational / Not Covered Codes

Investigational when used for electrical stimulation of OA and RA; therefore, not coveredHCPCSNot Covered

E0762

Electrical stimulation device, other than TENS

Investigational when used for medical equipment associated with investigational procedures addressed in this policy; therefore, not coveredHCPCSNot Covered

E1399

Durable medical equipment, miscellaneous

Investigational when used for miscellaneous electrical stimulation modalities addressed in this policy; therefore, not coveredCPT/HCPCSNot Covered

G0283	Electrical stimulation (unattended), to one or more areas, for chronic wound care
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended)
97032	Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes

Investigational when used for dry hydrotherapy; therefore, not coveredCPTNot Covered

97039

Unlisted modality (specify)

Investigational when used for radiofrequency therapy for wounds, edema, or plantar fasciitis; therefore, not coveredCPTNot Covered

24999	Unlisted procedure, humerus/shoulder area
27599	Unlisted procedure, femur/knee area
28899	Unlisted procedure, foot and toes

Provider Actions & Billing Rules

Documentation Required

InterQual applicability and cross-reference check

Confirm whether the patient's condition is listed in the InterQual Outpatient Rehabilitation guidelines; if it is, follow InterQual criteria. If a separate Capital Blue Cross policy exists for the modality, follow that policy's criteria.

If condition is in InterQual Outpatient Rehabilitation guidelines, follow InterQual.
If a separate Capital Blue Cross policy exists for the modality, follow that policy's criteria (cross-referenced policies listed).

Billing Rule

Do not bill investigational procedures for coverage

Claims for the listed investigational modalities and associated procedure/DME codes are considered not covered when used for the investigational indications specified in this policy. Do not bill these investigational procedures/codes for coverage for the conditions addressed as investigational in this policy.

Background

Background: Physical medicine includes active and passive therapeutic modalities intended to increase strength and endurance, improve ambulation, and assist patients with basic activities of daily living. A variety of electrical and electromagnetic stimulation devices and dry hydrotherapy (hydromassage/aquamassage) devices are marketed with claimed benefits for pain relief, improved circulation, increased range of motion, relaxation, and other physiologic effects. Examples of miscellaneous electrical stimulation modalities include Horizontal Therapy (Hako‑Med), High Voltage Galvanic Stimulation, and pre‑modulated electrical stimulation. Dry hydrotherapy devices are self‑contained beds or chairs that circulate heated, pressurized water beneath a waterproof barrier while the individual remains clothed and dry.

Rationale for policy stance: Several of these devices and therapies lack sufficient evidence demonstrating improved health outcomes. Therefore, the policy considers miscellaneous electrical stimulation modalities, electrical/electromagnetic stimulation for osteoarthritis and rheumatoid arthritis, radiofrequency therapy for wounds/edema/plantar fasciitis, and dry hydrotherapy as investigational for the indications noted and defers to InterQual outpatient rehabilitation guidelines and to separate Capital Blue Cross policies where applicable.

Definitions

Notes on evidence and definitions

Revision History

2024-08-06minor_review

Expanded investigational scope to explicitly include electrical stimulation for osteoarthritis and rheumatoid arthritis; coding updated (E0762 added as investigational).

2025-05-08minor_review

Clinical/coding changes affecting coverage: removed 'any other condition' from investigational statement for electrical stimulation for OA and RA; moved code 97039 to investigational for dry hydrotherapy; added codes 28899, 24999, and 27599 as investigational to represent radiofrequency therapies; other cross-reference updates and removals (G0281, G0282).

2025-09-09administrative_updateLatest