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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyHighmark Pennsylvania virtual pelvic health Covera…
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    CurrentHighmark PennsylvaniaPolicy N/A

    Virtual Pelvic Health (Bloom by Sword) — Coverage Criteria

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    Defines Highmark Pennsylvania's offering of Sword Health's virtual pelvic health program (Bloom) including eligibility, included components, exclusions, and enrollment instructions for members and referring providers.

    Policy Summary
    PayerHighmark Pennsylvania
    PolicyVirtual Pelvic Health (Bloom by Sword) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionRefer eligible members to the virtual pelvic health program; no prior authorization or cost-sharing is required and sessions do not count against PT benefit visits.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    61%members reporting significant symptom improvement
    32%reduction in likelihood of seeking other healthcare interventions

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    56% / 58%reduction in anxiety / depression
    No member costprogram offered at no additional cost

    Coverage and Eligibility

    Eligibility and coverage criteria

    Covered when ALL of the following are met

    Membership and demographic: Member is female (individuals with vaginal anatomy) aged >= 18 years and enrolled in a Limited Commercial Plan>= 18 years

    Program limited to eligible commercial plan members

    Clinical suitability: Condition appropriate for virtual pelvic health intervention (examples: pelvic floor disorders; bowel and/or bladder dysfunction; pregnancy and postpartum needs; menopause-related pelvic health concerns; intimacy wellbeing)N/A

    Complex cases or conditions requiring medical clearance (e.g., active pelvic infection, recent vaginoplasty without confirmed clearance, significant mental health risk) must be cleared before participation or are excluded

    Program availability and benefits: Member has access to the Bloom by Sword virtual pelvic health program delivered by licensed pelvic floor specialists and the Bloom Kit as appropriateN/A

    Program sessions do not count against allowed physical therapy benefit visits and are offered at no additional cost to eligible members

    Members enrolled in a Medicaid/Wholecare plan or a Medicare Advantage plan are not eligible for the program and are excluded from participation. Active pelvic infection requires physician clearance before enrollment; cases with complex clinical issues that need medical clearance must be cleared prior to participation. Individuals following vaginoplasty must have documented medical clearance before enrolling; if clearance is not confirmed or the post-operative timeline is unclear, the member is excluded. The policy also excludes members with significant mental health escalation (for example, imminent threat of harm to self or others, current inpatient mental health/substance-abuse care, worsening depression requiring focused clinical intervention, or victims of abuse) until those conditions are addressed by appropriate clinical services.

    This program is administered in partnership with Sword Health but any statements about corporate affiliation are administrative only and do not represent clinical exclusions beyond the stated medical criteria. Program participation decisions are based on the clinical eligibility and exclusion criteria listed in this policy, not on corporate or entity relationships.

    When a member’s clinical presentation requires medical clearance (for example, active pelvic infection, complex clinical cases, or post‑vaginoplasty care), enrollment is contingent on documentation of that clearance. If required medical clearance is not obtained or the post‑operative timeline is unclear (such as after vaginoplasty), the member is excluded from participation until clearance is provided.

    Provider Responsibilities and Enrollment

    Prior Authorization

    No member cost or PT benefit use

    Eligible members receive the Bloom virtual pelvic health program at no additional member cost and without prior authorization; program sessions do not count against the member’s allowed physical therapy benefit visits.

    • Program offered at no additional cost with no co-pays/coinsurance required (no member cost).
    • Sessions do not count against allowed PT benefit visits.
    • No prior authorization or member cost applies for eligible Limited Commercial plan members.
    Step Therapy

    When to see a specialist

    Refer patients to their specialist when the pelvic condition requires physician management; do not rely solely on the virtual program for issues needing medical or surgical care.

    • “Patients should see their Specialist to manage pelvic health issues requiring physician care.”

    Clinical Background

    Pelvic floor disorders and related conditions—such as bladder or bowel dysfunction, concerns with intimacy wellbeing, pregnancy/postpartum changes, and menopausal pelvic floor symptoms—are commonly managed with pelvic floor physical therapy. The virtual pelvic health program pairs licensed pelvic health clinicians with a home‑based system; however, certain clinical states change how the program is delivered. For example, no‑pod sessions (sessions that do not use the insertable sensor) are used for entire pregnancy, for the first 6 weeks postpartum, during an active pelvic infection with concurrent medical management, or when the member is unable to use the pod (for example, vaginal spasm or radiation scarring).

    Program Components and Terms

    Insertable sensor ('pod') — Bloom Kit definition and explanation
    Device nameBloom Kit insertable sensor ('pod')
    Primary functionMeasures pelvic floor exercises, provides real-time feedback, and tracks engagement
    Clinical oversightUsed within programs designed and monitored by Pelvic Floor Specialists / Licensed PTs
    Usage settingHome-based; sessions can be done anytime from anywhere
    Benefit interactionSessions using the pod do not count against allowed physical therapy benefit visits
    No-pod sessions — program sessions that do not use the insertable sensor, for pregnant patients, contraindications, or declined device use
    Policy Summary
    PayerHighmark Pennsylvania
    PolicyVirtual Pelvic Health (Bloom by Sword) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionRefer eligible members to the virtual pelvic health program; no prior authorization or cost-sharing is required and sessions do not count against PT benefit visits.
    SourceLink
    On This Page
    Coverage and EligibilityProvider Responsibilities and EnrollmentClinical BackgroundProgram Components and Terms
    Documentation Required

    Reporting and enrollment — patient reports and referral process

    Sword will provide care reports to the patient on request; the patient may then share those reports with their physician or care team. Referrals/enrollment are managed through the My Highmark app or member website as part of the enrollment process.

    • Sword shares care reports with the patient when requested; patient can share with their physician/care team.
    • Enrollment/referral is via My Highmark app or member website.
    Denial Risk

    Plan eligibility exclusions — Medicaid/Wholecare and Medicare Advantage

    Members enrolled in Medicaid/Wholecare plans or Medicare Advantage plans are excluded from the Bloom program and are not eligible to participate.

    • Excluded plans: Medicaid/Wholecare and Medicare Advantage.
    DefinitionProgram sessions that do not use the insertable sensor ('no-pod sessions')
    Intended patientsPregnant patients (entire pregnancy) and those within 6 weeks postpartum
    Clinical contraindicationsActive pelvic infection with concurrent medical management; inability to insert pod (e.g., vaginal spasm, radiation scarring)
    Patient preferenceAvailable for patients who do not wish to use the device
    Operational noteNo-pod sessions retain the virtual program structure but omit use of the insertable sensor