Title: 
Headings: Cigna Medical Coverage Policy- Therapy Services Physical Performance Test or Measurement
Cigna
 
Medical
 
Coverage
 
Policy-
 
Therapy
 
Services
 
Physical
 
Performance
 
Test
 
or
 
Measurement
 

INSTRUCTIONS
 
FOR
 
USE
 

If
 
coverage
 
for
 
return
 
to
 
work
 
services
 
are
 
available,
 
the
 
following
 
conditions
 
of
 
coverage
 
apply.
  

GUIDELINES
 

Medically
 
Necessary
 

Not
 
Medically
 
Necessary
  

Experimental,
 
Investigational
 
and/or
 
Unproven
 

DESCRIPTION
 

Functional
 
Capacity
 
Evaluation


 
Functional
 
Capacity
 
Evaluation
 
(FCE)
 
is
 
a
 
method
 
commonly
 
used
 
in
 
work
 
rehabilitation
 
for
 
assessing
 
the
 

Quantitative
 
Muscle
 
Testing
 
Devices
  

GENERAL
 
BACKGROUND
 

Functional
 
Capacity
 
Evaluation
  

Quantitative
 
Muscle
 
Testing
 
Devices
 

DOCUMENTATION
 
GUIDELINES
 

Functional
 
Capacity
 
Evaluation
 

LITERATURE
 
REVIEW
  

Coding/Billing
 
Information
 

Considered
 
Medically
 
Necessary
 
when
 
criteria
 
in
 
the
 
applicable
 
policy
 
statements
 
listed
  
above
 
are
 
met:
 

Considered
 
Educational
 
or
 
training
 
in
 
nature/Not
 
medically
 
necessary:
  

References
 


Content: The
 
evaluation
 
is
 
designed
 
to
 
determine
 
return
 
to
 
work
 
capabilities
 
following
 
a
 
defined
 
injury
 
or
 
following
 

 
medically
 
necessary
 
rehabilitation; The
 
evaluation
 
is
 
structured
 
to
 
answer
 
a
 
specific
 
question
 
or
 
questions
 
about
 
the
 
worker’s
 
performance
 
abilities
 
and
 
is
 
addressed
 
in
 
the
 
evaluation
 
report; Reported
 
results
 
must
 
be
 
compared
 
to
 
meaningful
 
standardized
 
norms; and
 


 
The
 
Functional
 
Capacity
 
Evaluation
 
must
 
be
 
performed
 
by
 
a
 
qualified
 
provider/evaluator
 
(see
 
requirements
 
below); and
 

 
Prior
 
to
 
the
 
FCE,
 
the
 
qualified
 
evaluator: Obtains
 
a
 
subjective
 
pain
 
assessment
 
with
 
self-reported
 
effect
 
on
 
functional
 
abilities
 
and
 
activities
 
of
 
daily
 
living
 


 
Performs
 
a
 
screening
 
examination
 


 
Obtains
 
informed
 
consent
 


The
 
FCE
 
is
 
typically
 
not
 
indicated
 
prior
 
to
 
three
 
months
 
post-injury,
 
unless
 
there
 
is
 
a
 
significant
 
documented
 
change
 
in
 
the
 
individual’s
 
status
 
which
 
justifies
 
earlier
 
performance. FCEs
 
are
 
limited
 
to
 
2-4
 
hours
 
per
 
date
 
of
 
service
 
and
 
one
 
evaluation
 
every
 
12
 
months
 
if
 
necessary. If
 
a
 
FCE
 
is
 
necessary
 
within
 
12
 
months,
 
cases
 
will
 
be
 
reviewed
 
individually
 
based
 
on
 
individual
 
client/patient
 
objective
 
data
 
compared
 
to
 
standardized
 
norms. A
 
FCE
 
may
 
extend
 
beyond
 
4
 
hours
 
or
 
two
 
days
 
to
 
further
 
quantify
 
the
 
ability
 
of
 
the
 
client
 
to
 
sustain
 
the
 
work
 
tasks
 
over
 

 
regular
 
work
 
schedule. The
 
length
 
of
 
the
 
FCE
 
is
 
dependent
 
upon: