What Is Medical Necessity?
Simply put, Medical Necessity means that a patient needs a healthcare service to restore their health and function. Medical Necessity is proven by establishing a patient’s specific functional limitations (such as sitting, standing, lifting, etc.), creating goals to restore lost function, and showing progress toward those goals.
Insurance companies and FSA/HSA plan administrators will only reimburse healthcare costs that are medically necessary.
Medically Necessary Massage Therapy is a targeted, clinical intervention prescribed to treat a specific diagnosed medical condition or conditions, restore physical function lost from injury, surgery, or pathology, and to reduce associated pain.
For patients, understanding medical necessity is essential when navigating insurance reimbursement – in our practice through Health Savings Accounts (HSAs), Flexible Spending Accounts (FSAs).
To establish medical necessity for medical massage therapy, documentation and clinical findings must meet the following criteria
Prescription or Referral
HSA/FSA plan administrators require a signed prescription or referral, from a primary care physician, physician assistant, nurse practitioner, chiropractor, osteopath, or other licensed medical provider.
Thorough Evaluation
Evaluation includes discussing your pain and other symptoms, assessing your posture, measuring range of motion and documenting deficits, and allows your therapist to understand your current condition, provide safe care by avoiding contraindications, tailor your treatment to your specific needs, and identify your functional limitations so we can make goals to track your progress.
Specific Treatment Goals
Medical Massage Therapy must have measurable, time bound, functional objectives, such as increasing range of motion, improving a patient’s capacity to lift, stand, sit, walk, etc., and restoring activities of daily living (ADLs).
Targeted Techniques
Medical Massage Therapy utilizes specialized clinical techniques—such as positional release therapy, IASTM (instrument assisted soft tissue mobilization), cupping therapy, kinesiology taping, myofascial release, linear and cross-fiber friction, as well as standard massage modalities such as deep tissue, applied specifically to restore function and decrease symptoms.
Progress and Re-evaluation
Treatment plans have a defined duration, with regular clinical re-evaluations to demonstrate measurable functional improvement and justify ongoing care.
All of this is to ensure that you as a patient get the specific care you need to heal, while successfully billing FSA/HSA accounts, and avoiding any potential denials.