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
 
FCE
 
is
 
based
 
on
 
the
 
observation
 
of
 
the
 
performance
 
of
 
the
 
physical
 
demands
 
of
 
work. FCEs
 
are
 
used
 
as
 
an
 
adjunct
 
method
 
of
 
making
 
judgments
 
of
 
performance
 
potential
 
and
 
readiness
 
for
 
work
 
following
 
a
 
musculoskeletal
 
injury. The
 
FCE
 
portion
 
of
 
this
 
guideline
 
is
 
for
 
where
 
care
 
management
 
is
 
being
 
rendered
 
for
 
individuals
 
who
 
have
 
musculoskeletal
 
conditions
 
that
 
are
 
medically
 
stable,
 
yet
 
demonstrate
 
limitation
 
of
 
function
 
and
 
disability
 
that
 
impairs
 
their
 
ability
 
to
 
work
 
at
 
full
 
capacity. Functional
 
Capacity
 
Evaluations
 
(FCEs)
 
provide
 
an
 
objective
 
measurement
 
system
 
to
 
evaluate
 
activity
 
and
 
activity
 
limitations
 
with
 
the
 
specific
 
purpose
 
of
 
matching
 
physical
 
abilities
 
with
 
essential
 
and
 
critical
 
job
 
demands. FCEs
 
also
 
assist
 
with
 
identifying
 
job
 
modifications
 
to
 
enhance
 
worker
 
safety
 
and
 
delineating
 
functional
 
capacities
 
in
 
case
 
of
 
litigation,
 
impairment
 
and
 
disability. The
 
focus
 
of
 
the
 
FCE
 
is
 
on
 
the
 
job
 
demands
 
and
 
the
 
performance
 
of
 
the
 
job
 
demands. Historically,
 
return-to-work
 
decisions
 
were
 
based
 
upon
 
diagnoses
 
and
 
prognoses
 
of
 
physicians,
 
but
 
did
 
not
 
include
 
objective
 
work
 
func