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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.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
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.
05/26/2016: Policy number added. Investigative definition updated in Policy Guidelines section.
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.