Does Anthem Blue Cross Blue Shield cover RTM?

What the document says

Applies to Elevance's Blue plans across 14 states: CA, CO, CT, GA, IN, KY, ME, MO, NV, NH, NY, OH, VA, WI. Requires ALL of: clinically appropriate per accepted standards; data regularly assessed to detect acute change and prompt intervention; not primarily for convenience; patient at risk of clinically significant change; patient unable to access regularly scheduled outpatient care OR monitoring required between visits; monitoring reasonably likely to prevent avoidable deterioration. NOT medically necessary where similar services are provided concurrently, home health being the example given.

RTM codes the document addresses:

• 98975
• 98976
• 98977
• 98978
• 98979
• 98980
• 98981
• 98984
• 98985
• 98986

The six criteria

CG-MED-91 calls RTM medically necessary when the record documents all of these:

1. Clinically appropriate per accepted standards.
2. The data is regularly assessed to detect acute changes in clinical status and prompt intervention.
3. Not primarily for convenience.
4. The patient is at risk of a clinically significant change that warrants enhanced monitoring.
5. The patient is unable to access regularly scheduled outpatient care, or monitoring is required between visits.
6. Monitoring is reasonably likely to prevent avoidable deterioration.

It is not medically necessary where similar services are provided concurrently, with home health as the example. Criteria 2 and 5 are documentation questions: a time log that shows the data was reviewed, and a note on why the patient needs monitoring between visits.

Check the plan, not just the carrier

About 67% of covered workers are in self-funded employer plans. The employer carries the risk, the carrier only administers it, and the employer's plan document governs. It can differ from the carrier's published policy. Cigna says so in its own instructions for use:

"In the event of a conflict, a customer's benefit plan document always supersedes the information in the Coverage Policies."

So a carrier policy narrows the question. It does not answer it for one patient. Call, name the codes, and write the answer down.

Other payers

How to use this page

This is a summary of a published payer document. It is not coverage advice and it cannot tell you whether one patient's claim will pay. The line of business, the employer's plan document and the patient's eligibility all sit between a policy and a payment. Our coverage guide walks through how to verify for a specific patient, and how to bill RTM covers the rest of the claim.

Policies change, usually in January. If you have a newer document or a remittance that contradicts this page, send it to contact@rehabityhealth.com and we will update the page.

Rehabity builds home exercise and remote therapeutic monitoring software for outpatient physical therapy clinics. We researched payer policy because we needed the answer ourselves. If you want to see what we build, read about the therapist side or join the waitlist.