Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rotator cuff tear.
Treatment:  Physical therapy x 10 additional visits.

The insurer denied coverage for physical therapy x 10 additional visits.  The denial is upheld.

This is a patient with a history of osteoarthritis (OA), high cholesterol, diabetes, and strain of muscle(s) and tendon(s) of the right shoulder rotator cuff. The patient is status post rotator cuff repair and subacromial decompression (SAD). The post-operative course has been uncomplicated, and treatment history has included physical therapy. Physical therapy (PT) treatments included strengthening, modalities for pain relief, range of motion exercises, neuromuscular reeducation, and implementing a home exercise program (HEP). The patient is noted to be demonstrating compliance with a home exercise program.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.   

The physical therapy x 10 additional visits are not considered medically necessary for this patient. 

In this case, this patient has completed physical therapy (PT) in the past. There is no documented failure to respond to a home exercise program (HEP) and/or indication that residual deficits could not be addressed within the context of a self-directed home exercise program. As such, this request for physical therapy x 10 additional visits is not medically necessary.

Sgroi, T. A., & Cilenti, M. (2018), "During rehabilitation after rotator cuff repair, there should be constant communication with the surgical team. Awareness of complication management, healing potential of the repaired tendon, and anatomy of the shoulder complex are critical. During the early stages, reducing pain and inflammation should be prioritized followed by progressive restoration of range of motion. When advancing range of motion, progression from passive, active assisted, and active movements allow for gradual introduction of stress to the healing construct. Even though time frames are not used for progression, it is important not to place excessive stress on the shoulder for up to 12 weeks to allow for proper tendon-to-bone healing. As exercises are progressed, scapular muscle activation is initiated, followed by isometric and lastly isotonic rotator cuff exercises. When treating overhead athletes, advanced strengthening in the overhead position is performed, followed by plyometric training. Advanced strengthening is initiated when all preceding criteria have been met. It is important that patients are educated early in the rehabilitation process so that they can manage their expectations to realistic time frames."

Mollison, S., Shin, J. J., Glogau, A., & Beavis, R. C. (2017), "The average response rate per question was 22.7%, representing an average of 704 total responses per question. The most common immobilization device was an abduction pillow sling with the arm in neutral or slight internal rotation (70%). Surgeons tended toward later unrestricted passive shoulder range of motion at 6 to 7 weeks (35%). Strengthening exercises were most commonly prescribed between 6 weeks and 3 months (56%). Unrestricted return to activities was most commonly allowed at 5 to 6 months. The majority of the respondents agreed that they would change their protocol based on differences expressed in this survey."                                                         

The insurer's denial of coverage for physical therapy x 10 additional visits is upheld. Medical Necessity is not substantiated.