CurrentHighmark Blueshield NenyPolicy N/A

Virtual Pelvic Health Program (Bloom by Sword) — Coverage Criteria

Defines Highmark's virtual pelvic health program (Bloom by Sword) for eligible Highmark members, describing program features, eligibility/exclusion criteria, and member experience. Applies to Highmark members in the jurisdictions covered by this document.

Policy Summary

PayerHighmark Blueshield Neny

PolicyVirtual Pelvic Health Program (Bloom by Sword) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain initial virtual evaluation by a licensed pelvic health PT who documents eligibility and exclusion assessment before enrolling the member.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Bloom kitBiofeedback kit

pelvic pain & relatedEligible conditions

18+Minimum age

active cancer, major comorbiditiesKey exclusions

Doesn't countVisit counting

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria & Exclusions

Enrollment eligibility and exclusion logic

Covered when ALL of the following are met and NO exclusion applies:

Enrollment prerequisites: Member is >= 18 years old; must have vaginal anatomy where specified by the program; member is covered by a self-insured (ASO) plan that has opted into the Virtual Physical Care program powered by Sword; member enrolls via the Highmark member portal and completes an initial virtual evaluation by a licensed pelvic health physical therapist.

From eligibility statements

Exclusion criteria (any): Any one of the following exclusion conditions will make the member ineligible for virtual care as determined by the PT: receiving active cancer treatment; certain neurological, cardiac, respiratory, or similar health conditions; high fall risk or significant loss of coordination; inability to bear weight on a lower limb or follow commands; significant trauma to the affected area within the prior 3 months; fracture or suspected fracture; pain from non-musculoskeletal causes; symptoms concerning for cancer (if suspected by PT or not previously addressed); complicated or high-risk pregnancy — within 6 weeks postpartum or within the first trimester of pregnancy.

PT will determine if condition makes patient ineligible

Exclusion criteria disqualify a member from enrollment in the virtual pelvic health program when any listed condition is present or when the treating pelvic health physical therapist determines the condition makes virtual care unsafe or inappropriate. Examples include: patients receiving active cancer treatment; specified neurological, cardiac, respiratory, or similar health conditions; those at high fall risk or with significant loss of coordination; inability to bear weight on a lower limb or follow commands; significant trauma to the affected area within 3 months or a fracture or suspected fracture; pain from non‑musculoskeletal causes; symptoms concerning for cancer (when suspected by the PT or not previously addressed); and complicated or high‑risk pregnancy, including within 6 weeks postpartum or within the first trimester.

The policy does not enumerate additional formal Not Medically Necessary (NMN) scenarios beyond the exclusion list; instead, NMN-equivalent determinations are made when the pelvic health PT assesses a member during the initial virtual evaluation and determines the patient is ineligible for virtual care due to clinical risk or safety concerns. The PT documents this determination and the clinical rationale, which effectively excludes the member from program participation.

Provider Responsibilities & Enrollment

Prior Authorization

Enrollment / Plan opt‑in requirement

Members must be covered by a self‑insured (ASO) plan that has opted into Highmark's Virtual Physical Care program powered by Sword. Confirm plan opt‑in/participation before enrollment; members whose ASO plans have not opted in are not eligible for enrollment in the Virtual Pelvic Health (Bloom by Sword) program.

ASO plan must have formally opted into the Virtual Physical Care program powered by Sword
Verify member's plan participation prior to scheduling or shipping the Bloom kit

Denial Risk

Exclusion‑based denial triggers

Patients meeting any of the following should generally be denied enrollment in the virtual program or referred for in‑person evaluation and management. The PT must screen for these exclusions during the initial evaluation and document the findings.

Receiving active cancer treatment

Clinical Background & Scope

The virtual pelvic health program addresses a range of pelvic conditions managed by pelvic health physical therapists, including pelvic pain, bowel and bladder disorders, concerns related to sexual/intimacy wellbeing, pelvic health needs during pregnancy and the postpartum period, and symptom relief associated with menopause.

Program Components & Definitions

inv-09: Bloom kit — description of insertable pressure‑sensing pod kit provided to members

What it isA member-delivered kit issued after the initial PT visit that includes an insertable pressure‑sensing pod used during pelvic floor exercises.

PurposeProvides real‑time intravaginal pressure sensing to enable biofeedback during prescribed pelvic floor exercise programs.

When providedSupplied to members after meeting with the licensed pelvic health physical therapist who designs the custom program.

How it’s usedInserted by the member and paired with the Sword app to capture pressure data while performing exercises; data is used by the PT to adjust the program.

ComponentsIncludes an insertable pressure‑sensing pod (and associated connectivity components as needed) to work with the Sword mobile app.

Documentation Required

Required evaluation and documentation

Initial evaluation must be performed virtually by a licensed pelvic health physical therapist (PT) who documents the clinical assessment and the rationale for delivering care virtually. Documentation should include: presenting diagnosis and symptoms, relevant medical history, safety assessment (fall risk, weight‑bearing status, neurologic/cardiac/respiratory stability), pregnancy status, prior cancer treatment or active cancer therapy, and the PT's determination of eligibility for virtual care. The PT must also document informed consent for virtual care and record the plan of care and device (Bloom kit/pod) instruction if enrolled.

Initial virtual evaluation by a licensed pelvic health PT is required and must be documented in the medical record
Document: presenting complaint, past medical/surgical history, medications, safety/fall risk assessment, pregnancy status, cancer treatment status, and any limitations affecting virtual participation
Document PT's clinical decision that the patient is appropriate for virtual care and the informed consent discussion
Document plan of care, exercise program, and instructions for use of the Bloom kit and pressure‑sensing pod
If excluded during evaluation, document reasons for non‑enrollment and referral recommendations