Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple sclerosis
Treatment: Physical therapy
The insurer denied the Physical therapy.
The denial is upheld. 

The patient, a male, has a history of multiple sclerosis.  His symptoms include spasticity, generalized weakness, fatigue, poor endurance and bladder dysfunction.  He is reported by his physician to be "wheelchair bound."  Continued physical therapy at the home was recommended to "prevent decline of physical and functional status in order to maintain clinical status and safety at home," including to stabilize his disease process, maintain his independence, minimize his deconditioning and decrease hospital admissions.

Home health care notes report that the patient has multiple contractures and stage IV pressure ulcers at the sacrum and right hip.  He is described in home health care provider notes as "homebound" and "bedbound."  He is reported to have trace upper and lower limb strength, with poor coordination.  He is reported to require maximum assistance for bed mobility and transfers.  He is reported to be non-ambulatory and to require maximum assistance with wheelchair activities and activities of daily living.  Additional home based physical therapy has been recommended for active assisted and passive range of motion, postural training, mobility training, caregiver education, and additional training/education on task performance.

No, the proposed physical therapy is not medically necessary.

The records do not indicate that the patient is able to actively participate in physical therapy in a meaningful way.  The patient is documented to have only trace motor strength throughout, poor coordination and multiple contractures.  

The patient requires passive range of motion, active-assisted range of motion, turning in bed (dependently), maximum to total assistance for transfers out of bed, and maximum to total assistance for basic self-care.  These tasks can be performed by unskilled caregivers.  The records do not indicate that the patient would be able to actively participate in therapies or that he would be expected to benefit from continued home-based physical therapy.  The records indicate that he is at a dependent level of care overall and that continued home-based physical therapy is not medically necessary.

Multiple sclerosis (MS) is an immune-mediated, demyelinating and neurodegenerative disease of the central nervous system.  MS is a major cause of chronic neurological disability in young and middle-aged adults (1, 2).  Treatment involves controlling acute attacks, managing and preventing underlying disease progression, managing symptomatology, and managing the progressive functional impairments associated with the disease.

Rehabilitation can play a significant role in addressing the functional issues related to multiple sclerosis.  A recent Cochrane review of reviews found moderate quality evidence for physical therapy modalities (i.e., exercise and physical activities) in improving functional outcomes (i.e., mobility, strength and aerobic capacity), reducing fatigue, and improving participation/quality of life (1).  Moderate evidence was also found for multidisciplinary rehabilitation programs and educational interventions improving patient knowledge.  There was found to be low-quality evidence for neuropsychological interventions, spasticity management programs, whole body vibration therapy, telerehabilitation and vocational interventions.  Exercise, in particular, has been identified as a beneficial rehabilitation strategy for persons with multiple sclerosis to manage symptoms, restore function, optimize quality of life, promote wellness, and boost participation in activities of daily living (4, 5, 6).

In the current case, the records provide strong indications that the patient has advanced disease with profound functional impairments.  He has only trace residual motor functionality and has many of the sequelae of chronic and severe immobility, including multiple contractures and multiple stage IV pressure ulcers.  The records indicate that the patient is outside of the window where he can actively and meaningfully participate in exercise and rehabilitation interventions such as physiotherapy.  Passive range of motion and repositioning maneuvers for comfort and pressure ulcer management can be provisioned by caregivers or other persons providing custodial level of care.  The records indicate that the health plan acted reasonably in denying coverage of ongoing home-based physiotherapy based on the patient's circumstances.