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Hydrotherapy refers to the use of water in the treatment of disease or trauma. The patient lies on the surface of a hydrotherapy table completely clothed. A mattress filled with heated water is under the surface of the table. A pump propels the water toward the patient through hydro-jets. The pressure of the water against the patient’s body provides the massage. The therapy can be applied to nearly every part of the body simply by changing the patient’s position. This is unattended hands-free massage.
Dry hydromassage is considered investigational.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY11/2003: Approved by Medical Policy Advisory Committee (MPAC)
1/21/2004: Code Reference section completed
10/13/2006: Policy reviewed, no changes
10/30/2013: Policy reviewed; no changes to policy statement. Added Aetna Clinical Policy to Sources section.
07/14/2015: Code Reference section updated for ICD-10.
SOURCE(S)Highmark Blue Cross Blue Shield
Aetna Clinical Policy Bulletin: Dry Hydrotherapy (Hydromassage, Aquamassage, Water Massage)
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.