Effective April 30, 2019, AmeriHealth updated its commercial preventive coverage for prevention of falls, in accordance with recent recommendations from the U.S Preventive Services Task Force (USPSTF). USPSTF recommends exercise interventions to prevent falls in community-dwelling (i.e., not living in a facility) adults 65 years or older who are at increased risk for falls. Based on clinical studies, the most common components of exercise were gait training, balance training, functional training, resistance training, flexibility, and endurance training.

As communicated on April 29, 2019, in the Preventive Coverage of Exercise Interventions for the Prevention of Falls Medical Policy news article (effective April 30, 2019), AmeriHealth covers exercise interventions (i.e., physical therapy) as a preventive service, with $0 cost-share, for community-dwelling commercial members 65 years of age or older who are at increased risk for falls when the following criteria are met:

• The individual is not diagnosed with osteoporosis or vitamin D deficiency.
• The exercise interventions include at least one of the following components:
  • gait training
  • balance training
  • functional training
  • resistance training
  • flexibility
  • endurance training

The exercise intervention services are only reimbursed as preventive, with $0 cost-share, when the preventive criteria are met and reported with eligible procedure codes, appropriate diagnosis codes, appropriate modifiers, and the appropriate place of service code. A list of eligible procedure codes, and appropriate diagnoses and modifier codes is included in the Medical Policy News article.

Exercise interventions that meet the preventive criteria will be considered part of the member’s preventive benefit. Exercise interventions (i.e., physical therapy) that do not meet the preventive criteria will be covered under the member’s medical benefit and, therefore, subject to applicable cost-sharing and limits on the number of visits based on the terms of the member’s benefit contract.

For more information

The coverage information from the news article will be incorporated accordingly into commercial Medical Policy #00.06.02: Preventive Care Services (AmeriHealth).

To view the news article, visit our Medical Policy Portal and select Accept and Go to Medical Policy Online. Then type the article title, policy name, or policy number in the Search field.