ModifiedCapital BluecrossPolicy MP 8.001

Investigational Physical Medicine and Specialized Physical Medicine Interventions (Outpatient)

Defines investigational (not medically supported) outpatient physical medicine modalities and equipment and the conditions/products to which this applies for Capital Blue Cross members and providers.

Policy Summary

PayerCapital Bluecross

PolicyInvestigational Physical Medicine and Specialized Physical Medicine Interventions (Outpatient)

Policy CodePolicy MP 8.001

Change TypeInvestigational designations and coding updates

Effective Date11/1/2025

Next Review Date

Key ActionVerify member eligibility and benefits and reference updated coding when submitting claims for services designated investigational (e.g., E0762, 97039, 28899, 24999, 27599).

SourceLink

POLICY UPDATE CHANGES

Added electrical stimulation for osteoarthritis, rheumatoid arthritis, or any other condition as investigational.

Added dry hydrotherapy as investigational.

Changed title and removed certain therapy statements (e.g., aquatic therapy, vestibular therapy) and some codes.

Added electrical stimulation for osteoarthritis, rheumatoid arthritis, or any other condition as investigational and added code E0762 as investigational.

Removed 'any other condition' from investigational status for electrical stimulation for OA and RA; moved code 97039 to investigational to represent dry hydrotherapy; removed G0281 and G0282; added 28899, 24999, and 27599 as investigational to represent radiofrequency therapies.

Added Dry Hydrotherapy as investigational.

Removed Benefit Variations Section and updated Disclaimer.

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Coverage Criteria — Investigational Modalities

Investigational modalities (not covered)

Covered only when NOT investigational; the following are considered investigational for all conditions due to insufficient evidence:

Investigational modalities: Includes miscellaneous electrical stimulation modalities such as Horizontal Therapy (Hako-Med), High Voltage Galvanic Stimulation (HVG), pre-modulated electrical stimulation, and electrical or electromagnetic stimulation for osteoarthritis and rheumatoid arthritis; radiofrequency therapy for treatment of wounds, edema, or plantar fasciitis; and dry hydrotherapy (hydromassage/aquamassage).

These modalities are considered investigational for all conditions per policy due to insufficient evidence of benefit.

Investigational — Services and codes designated investigational per policy history

Services and codes designated investigational per policy history

Investigational services: Policy history designates electrical stimulation for osteoarthritis and rheumatoid arthritis as investigational; dry hydrotherapy (moved to investigational with code 97039) and radiofrequency procedures (represented by unlisted procedure codes 28899, 24999, 27599) are investigational. Specific codes have been added, moved, or removed in policy updates (see coding module for exact designations).

Refer to the coding section for the full list of codes added as investigational (for example, E0762 added; 97039 moved to investigational; 28899/24999/27599 added).

Coverage exclusions listed in this policy do not apply to members or groups whose benefits are governed by Pennsylvania Act 62 of 2008, Section 635.2, regarding Autism Spectrum Disorders coverage.

Services and procedure codes designated as investigational in the policy history are excluded from coverage. Recent history documents the addition or movement of several codes to investigational status (for example, addition of E0762, movement of 97039 to investigational, and addition of unlisted procedure codes 28899, 24999, and 27599 to represent radiofrequency therapies).

The policy identifies the following modalities and clinical contexts as investigational due to insufficient evidence of benefit: miscellaneous electrical stimulation modalities (including Horizontal Therapy/Hako‑Med, High Voltage Galvanic Stimulation, and pre‑modulated electrical stimulation, and electrical/electromagnetic stimulation for osteoarthritis and rheumatoid arthritis), radiofrequency therapy when used for wounds, edema, or plantar fasciitis, and dry hydrotherapy (also called hydromassage or aquamassage).

Policy history clarifies that services labeled investigational are treated as not covered (not medically necessary) for purposes of this policy. Multiple updates record additions and revisions to investigational designations and corresponding code changes, informing which procedures and codes are excluded from coverage.

Coding — Investigational Code Lists and Billing Notes

Investigational when used for electrical stimulation of OA and RAHCPCSNot Covered

E0762

Electrical stimulator supplies (investigational when used for electrical stimulation of OA and RA)

Investigational when used for medical equipment associated with investigational proceduresHCPCSNot Covered

E1399

Unlisted miscellaneous durable medical equipment (investigational when used for medical equipment associated with investigational procedures)

Investigational when used for miscellaneous electrical stimulation modalitiesmixedNot Covered

G0283	Unattended electrical stimulation (investigational when used for miscellaneous electrical stimulation modalities addressed in this policy)
97014	Electrical stimulation (unattended) (investigational when used for miscellaneous electrical stimulation modalities addressed in this policy)
97032	Electrical stimulation (manual), other than interferential current, iontophoresis, or TENS (investigational when used for miscellaneous electrical stimulation modalities)

Investigational when used for dry hydrotherapyCPTNot Covered

97039

Hydrotherapy (dry hydrotherapy/hydromassage) (investigational when used for dry hydrotherapy)

Investigational when used for radiofrequency therapy for wounds, edema, or plantar fasciitisCPTNot Covered

24999	Unlisted procedure (investigational when used for radiofrequency therapy for wounds, edema, or plantar fasciitis)
27599	Unlisted procedure (investigational when used for radiofrequency therapy for wounds, edema, or plantar fasciitis)
28899	Unlisted procedure (investigational when used for radiofrequency therapy for wounds, edema, or plantar fasciitis)

Investigational / policy code changesmixedNot Covered

E0762	Electrical stimulation device (added as investigational)
97039	Physical therapy procedure code moved to investigational to represent dry hydrotherapy
G0281	Removed from policy
G0282	Removed from policy
95992	Removed from policy
97113	Removed from policy
97533	Removed from policy
S9476	Removed from policy
28899	Unlisted procedure — added as investigational to represent radiofrequency therapies
24999	Unlisted procedure — added as investigational to represent radiofrequency therapies

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Direct physical therapy access duration

Direct access durationCertificate holder may treat without referral for up to 30 calendar days from the date of the first treatment

Referral requirement after 30 daysA physical therapist may not treat a person beyond 30 days from the date of the first treatment unless the person has obtained a referral from a licensed physician, dentist, or podiatrist.

Definition of date of first treatmentThe date of the first treatment is the date the person is treated by any physical therapist treating without a referral.

Scope limitationsA certificate holder may not treat non‑neurologic, nonmuscular, or non‑skeletal conditions, or persons with an acute cardiac or acute pulmonary condition, without consultation or referral to a licensed physician, dentist, or podiatrist.

Provider Actions — Authorization, Documentation, and Denial Risk

Note

Program / Product Variations — verify benefits

This policy is applicable only to certain Capital Blue Cross programs and products; benefit variations may apply. Providers should verify member-specific coverage and whether prior authorization is required under the member's benefit plan before rendering services.

Applicable programs/products may vary — check member benefit plan.
FEP PPO members: refer to the FEP Medical Policy Manual at https://www.fepblue.org/benefit-plans/medical-policies-and-utilization-management-guidelines/medical-policies

Documentation Required

Documentation and Verification — include supporting clinical records

When submitting claims for services described in this policy, include documentation that supports medical necessity and clearly links billed procedure codes to the member's diagnosis and the specific services provided. Reference the policy history and coding guidance to ensure accurate code selection.

Include clinical records demonstrating medical necessity.

Background — Physical Medicine Interventions

Physical medicine interventions addressed in this policy encompass therapeutic exercise and a range of passive and active modalities intended to improve strength, endurance, ambulation, and performance of basic activities of daily living. The policy specifically evaluates certain specialized modalities — particularly several electrical/electromagnetic stimulation techniques and dry hydrotherapy — and concludes that available evidence is insufficient to support their use for the listed indications, resulting in investigational (noncovered) status for those modalities.

Definitions

Basic activities of daily living definition

DefinitionBasic activities of daily living include and are limited to walking in the home, eating, bathing, dressing, and homemaking.

Examples — mobilityWalking in the home

Examples — self‑careEating, bathing, dressing

Examples — household tasksHomemaking

Maintenance program definition

DefinitionMaintenance program is a therapy program that consists of activities that preserve the patient's present level of function and prevents regression of that function.

Policy Summary

PayerCapital Bluecross

PolicyInvestigational Physical Medicine and Specialized Physical Medicine Interventions (Outpatient)

Policy CodePolicy MP 8.001

Change TypeInvestigational designations and coding updates

Effective Date11/1/2025

Next Review Date

Key ActionVerify member eligibility and benefits and reference updated coding when submitting claims for services designated investigational (e.g., E0762, 97039, 28899, 24999, 27599).

SourceLink

On This Page

Direct access — additional requirements

State Board certificate requirementDirect Physical Therapy Access applies to physical therapists with a certificate of authorization to practice without a physician's referral.

Display of certificateThe certificate of authorization shall be displayed by the certificate holder in a manner conspicuous to the public.

Renewal timingThe renewal of the certificate of authorization shall coincide with the renewal of the license of the licensee.

Consultation requirementCertificate holders must consult with the person's licensed physician, dentist or podiatrist regarding the condition and treatment plan before treating excluded conditions without referral.

Denial Risk

Denial Risk — investigational services and codes

Investigational services identified in this policy are considered not covered. Claims for investigational procedures or investigational-use equipment may be denied. Providers should review the coding list in Section VI and the policy history when preparing authorizations and claims.

Investigational codes include (examples): E0762, E1399, G0283, 97014, 97032, 97039, 24999, 27599, 28899.
Claims for these codes for indications listed as investigational may be denied.
Review policy history for recent additions or moved investigational codes before claim submission.

Note

Investigational Code Designations — verify moved/added codes

Addition or relocation of investigational code designations has occurred in recent updates. Always confirm the current investigational status of procedure codes prior to ordering or billing to avoid denials.

Codes moved to investigational status in 2025 include 97039 and radiofrequency-related codes (24999, 27599, 28899).
Removed codes (e.g., G0281, G0282) and added codes are documented in policy history — verify current list.