Standpunt gesuperviseerde oefentherapie bij artrose van heup of knie
Bijlage 2: Systematische review van het Erasmus MC
5.3 Standpunt Zorginstituut Nederland
Het Zorginstituut concludeert dat gesuperviseerde oefentherapie onder supervisie ven een fysio- of oefentherapeut met een duur van 8-12 weken (maximaal 12 behandelsessies) bij patiënten met klinische artrose van heup of klinische artrose van knie voldoet aan de stand van de wetenschap en praktijk.
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Bijlage 1: Overzicht van standpunten
Organisatie Omschrijving Standpunt Datum
Aetna http://www.aetna.com/cpb /medical/data/300_399/03 25.html Amerikaanse verzekeraar
Aetna considers physical therapy medically necessary when this care is prescribed by a chiropractor, DO, MD, nurse practitioner, podiatrist or other health professional qualified to prescribe physical
therapy according to State law in order to significantly improve, develop or restore physical functions lost or impaired as a result of a disease, injury or surgical procedure, and the following criteria are met:
• The member’s participating physician or licensed health care practitioner has determined that the member’s condition can improve significantly based on physical measures (eg, active range of motion (AROM), strength, function or subjective report of pain level) within one month of the date that therapy begins or the therapy services proposed must be necessary for the establishment of a safe and effective maintenance program that will be performed by the member without ongoing skilled therapy services. These services must be proposed for the treatment of a specific illness or injury; and
• The PT services provided are intended to cover only episodes of therapy for situations where there must be a reasonable expectation that a member’s condition will improve significantly in a reasonable and generally predictable period of time; and
• PT services must be ordered by a physician or other licensed health care practitioner and performed by a duly licensed and certified, if applicable, PT provider. All services provided must be within the applicable scope of practice for the provider in their licensed jurisdiction where the services are provided; and
• The services provided must be of the complexity and nature to require that they are performed by a licensed professional therapist or provided under their direct supervision by a licensed ancillary person as permitted under state laws. Services may be provided personally by physicians and performed by personnel under their direct supervision as permitted under state laws. As physicians are not licensed as physical therapists, they may not directly supervise physical therapy
assistants; and
• PT must be provided in accordance with an ongoing, written plan of care that is reviewed with and approved by the treating physician in accordance with applicable state laws and regulations. The PT plan of care should be of such sufficient detail and include appropriate objective and subjective data to demonstrate the medical necessity of the proposed treatment (see appendix for documentation requirements).
Physical therapy in asymptomatic persons or in persons without an identifiable clinical condition is considered not medically necessary. Physical therapy in persons whose condition is neither regressing nor improving is considered not medically necessary.
Once therapeutic benefit has been achieved, or a home exercise program could be used for further gains, continuing supervised physical therapy is not considered medically necessary.
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Organisatie Omschrijving Standpunt Datum
Anthem https://www.anthem.com/ medicalpolicies/guidelines/ gl_pw_a051172.htm Amerikaanse verzekeraar
This document addresses physical therapy (PT) services, skilled services which may be delivered by a physical therapist or other health care professional acting within the scope of a professional license. Physical therapy is used for both rehabilitation and habilitation.
Rehabilitative services are intended to improve, adapt or restore functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality involving goals an individual can reach in a reasonable period of time. Benefits will end when treatment is no longer medically necessary and the individual stops progressing toward those goals.
Habilitative services are intended to maintain, develop or improve skills needed to perform activities of daily living (ADLs) or instrumental activities of daily living (IADLs) (see definitions) which have not (but normally would have) developed or which are at risk of being lost as a result of illness, injury, loss of a body part, or congenital abnormality. Examples include therapy for a child who is not walking at the expected age.
The terms "physical therapy" and "physiotherapy" are synonymous.
Note: The availability of rehabilitative and/or habilitative benefits for these services, state and federal mandates, and regulatory requirements should be verified prior to application of criteria listed below. Benefit plans may include a maximum allowable physical therapy benefit, either in duration of treatment or in number of visits. When the maximum allowable benefit is exhausted, coverage will no longer be provided even if the medical necessity criteria described below are met.
Cigna https://cignaforhcp.cigna.c om/public/content/pdf/cov eragePolicies/medical/mm _0096_coveragepositioncri teria_physical_therapy.pdf Amerikaanse verzekeraar
Cigna covers a physical therapy evaluation as medically necessary for the assessment of a physical impairment. Cigna covers a prescribed course of physical therapy by an appropriate healthcare provider as medically necessary when ALL of the following criteria are met:
• The program is designed to improve lost or impaired physical function or reduce pain resulting from illness, injury, congenital defect or surgery.
• The program is expected to result in significant therapeutic improvement over a clearly defined period of time.
• The program is individualized, and there is documentation outlining quantifiable, attainable treatment goals.
Cigna does not cover physical therapy for the following as they are excluded from many benefit plans and considered not medically necessary when used for these purposes:
• treatment provided to prevent or slow deterioration in function or prevent reoccurrences • treatment intended to improve or maintain general physical condition
• long-term rehabilitative services when significant therapeutic improvement is not expected • when a home exercise program can be utilized to continue therapy
Page 3 of 25 Coverage Policy Number: 0096
• physical therapy that duplicates services already being provided as part of an authorized therapy program through another therapy discipline (e.g., occupational therapy) or services provided in another therapy environment (e.g., aquatic therapy does not duplicate therapy provided on land)
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Organisatie Omschrijving Standpunt Datum
educational or training in nature and thus are not medically necessary. In addition, these treatments/programs are specifically excluded under many benefit plans:
• back school
• group physical therapy (because it is not one-on-one, individualized to the specific person’s needs) • services for the purpose of enhancing athletic performance or for recreation
• vocational rehabilitation programs and any program with the primary goal of returning an individual to work
• work hardening programs
Premera Blue Cross https://www.premera.com /medicalpolicies/8.03.502. pdf
PT, including medical massage therapy services may be considered medically necessary when ALL of the following criteria are met:
- The patient has a documented condition causing physical functional impairment, or disability due to disease, illness, injury, surgery or physical congenital anomaly that interferes with Activities of Daily Living (ADLs) and
-The patient has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time based on specific diagnosis related treatment/therapy goals and
- Due to the physical condition of the patient, the complexity and sophistication of the therapy and the therapeutic modalities used; the judgment, knowledge, and skills of a qualified PM&R PT or medical massage therapy provider are required. A qualified provider is one who is licensed where required and performs within the scope of licensure
and
- PT and/or medical massage therapy services provide specific, effective, and reasonable treatment for the member’s diagnosis and physical condition consistent with a detailed plan of care.
PM&R PT and/or medical massage therapy services must be described using standard and generally accepted medical/physical/massage therapy/rehabilitation terminology. The terminology should include objective measurements and standardized tests for strength, motion, functional levels and pain. The plan should include training for selfmanagement for the condition(s) under treatment.
Services provided that are not part of a therapy plan of care, or are provided by unqualified staff are not covered. https://www.admin.ch/opc /de/classified- compilation/19950275/201 608010000/832.112.31.pd f
Die Kosten folgender Leistungen werden übernommen, wenn sie auf ärztliche Anordnung hin von
Physiotherapeuten und Physiotherapeutinnen im Sinne der Artikel 46 und 47 KVV oder von Organisationen im Sinne von Artikel 52 a KVV und im Rahmen der Behandlung von Krankheiten des muskuloskelettalen oder neurologischen Systems oder der Systeme der inneren Organe und Gefässe, soweit diese der Physiotherapie zugänglich sind, erbracht werden:
a. Massnahmen der physiotherapeutischen Untersuchung und der Abklärung; b. Massnahmen der Behandlung, Beratung und Instruktion:
1. aktive und passive Bewegungstherapie, 2. manuelle Therapie,
3. detonisierende Physiotherapie,
4. Atemphysiotherapie (inkl. Aerosolinhalationen), 5. medizinische Trainingstherapie,
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Organisatie Omschrijving Standpunt Datum
7. Bewegungstherapie im Wasser,
8. Physiotherapie auf dem Pferd bei multipler Sklerose, 9. Herz-Kreislauf-Physiotherapie,
10.Beckenboden
c. Physikalische Massnahmen: 1. Wärme- und Kältetherapie, 2. Elektrotherapie,
3. Lichttherapie (Ultraviolett, Infrarot, Rotlicht) 4. Ultraschall,
5. Hydrotherapie,
6. Muskel- und Bindegewebsmassage.
1bis Massnahmen nach Absatz 1 Buchstaben b Ziffern 1, 3–5, 7 und 9 können in Einzel- oder Gruppentherapie durchgeführt werden.
1ter Die medizinische Trainingstherapie beginnt mit einer Einführung in das Training an Geräten und ist maximal drei Monate nach der Einführung abgeschlossen. Der medizinischen Trainingstherapie geht eine physiotherapeutische Einzelbehandlung voran.
2 Die Versicherung übernimmt je ärztliche Anordnung die Kosten von höchstens neun Sitzungen, wobei die erste Behandlung innert fünf Wochen seit der ärztlichen Anordnung durchgeführt werden muss.
3 Für die Übernahme von weiteren Sitzungen ist eine neue ärztliche Anordnung erforderlich.
4 Soll die Physiotherapie nach einer Behandlung, die 36 Sitzungen entspricht, zu Lasten der Versicherung fortgesetzt werden, so hat der behandelnde Arzt oder die behandelnde Ärztin dem Vertrauensarzt oder der Vertrauensärztin zu berichten und einen begründeten Vorschlag über die Fortsetzung der Therapie zu unterbreiten. Der Vertrauensarzt oder die Vertrauensärztin prüft den Vorschlag und beantragt, ob, in welchem Umfang und für welche Zeitdauer bis zum nächsten Bericht die Physio-therapie zu Lasten der Versicherung fortgesetzt werden kann.
5 Bei Versicherten, welche bis zum vollendeten 20. Altersjahr Anspruch auf Leis- tungen nach Artikel 13 des Bundesgesetzes vom 19. Juni 1959 über die Invaliden-versicherung haben, richtet sich die
Kostenübernahme für die Fortsetzung einer bereits begonnenen Physiotherapie nach dem vollendeten 20. Altersjahr nach Absatz4
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Bijlage 2: Referenties
i Richtlijn Diagnostiek en behandeling van heup- en knieartrose. CBO 2007
ii NHG- standaard Niet-traumatische knieklachten M107 (Actualisering februari 2016) iii Wat is artrose en wat is het beloop? Nationaal Kompas Volksgezondheid.
iv
World Health Organization. WHO methods and data sources for global burden of disease estimates 2000‐2011. Beschikbaar via: http://www.who.int/healthinfo/statistics/GlobalDALYmethods_2000_2011.pdf?ua=1
v Altman R, Alarcon G, Appelrouth D et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum 1991; 34: 505-14.
vi Altman R, Asch E, Bloch D et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum 1986; 29: 1039.
vii KNGF Beroepsprofiel Fysiotherapeut. 2014. (
http://www.thim.nl/files/8914/4542/6965/KNGF_Beroepsprofiel_Fysiotherapeut_2014.pdf)
viii de Groot I, Reijman M, Terwee CB, Bierma-Zeinstra SM, Favejee M, Roos EM, et al. Validation of the Dutch version of the Hip disability and
Osteoarthritis Outcome Score. Osteoarthritis Cartilage. 2007 Jan;15(1):104-9
ixde Groot I, Favejee MM, Reijman M, Verhaar JA, Terwee CB. The Dutch version of the Knee Injury and Osteoarthritis Outcome Score: a validation
study. Health Qual Life Outcomes. 2008;6:16.
x
Roorda LD, Jones CA, Waltz M, Lankhorst GJ, Bouter LM, Eijken JW van der, et al. Satisfactory cross cultural equivalence of the Dutch WOMAC in patients with hip osteoarthritis waiting for arthroplasty. Ann Rheum Dis. 2004 Jan;63(1):36-42.
xi Veenhof C, Bijlsma JW, Ende CH van den, Dijk GM van, Pisters MF, Dekker J. Psychometric evaluation of osteoarthritis questionnaires: a systematic review of the literature. Arthritis Rheum. 2006 Jun 15;55(3):480-92.
xii Terwee CB, Roorda LD, Dekker J. et al. Mind the MIC: large variation among populations and methods. J Clin Epid 2010;63:524-34.
xiii Members PP, Philadelphia Panel Evidence-Based Clinicial Practice Guidelines on selected rehabilitation interventions: overview and Methodology. Physical Therapy, 2001;81(10):1629-40.