Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Velas 60w laser therapy, decompression therapy, functional neuro-ortho services, intersegmental traction, hydrotherapy, massage therapy, vibration plate therapy, and/or a home care instruction kit. The patient in this case is reported to have chronic low back pain, sciatica, neuropathy, arthralgias and muscular weakness with atrophy. The patient has undergone bariatric surgery and lost weight, but he remains obese. The patient presents with functional difficulties. The management of chronic musculoskeletal, neurological and functional complaints can include pharmacological agents, rehabilitation, psychological treatment, complementary/alternative medicine and invasive approaches. The aim of rehabilitation is to reduce pain, reduce impairment, and improve quality of life (Urits, et al.). Formal rehabilitative interventions can be rendered, in conjunction with education, towards a goal of self-management, independent exercise and remaining active. Exercise and physical activity, in particular, have low risks for adverse effects and are generally encouraged in the setting of these types of chronic pain (Geneen, et al.; Oliveira, et al.). However, the records do not establish that this patient has impairments that preclude participation in an independent water-based or low-impact land-based exercise program to initiate his exercise-based rehabilitation. There is a lack of documented impairments or other objective indications that the patient is unable to exercise in a pool on his own, in a group exercise setting, or with an exercise coach. Hydrotherapy is indicated for patients who require therapy in a partially body weight unloaded environment and are unable to perform the applicable exercises without guidance, instruction, and supervision from a skilled provider. The records do not indicate that this patient meets these requirements. Moreover, the benefit of formal passive modalities such as low level laser therapy, traction/decompression therapy, vibration therapy and massage therapy over self-applied palliative modalities such as hot or cold packs and independently rendered massage therapy is not supported in the medical literature for management of this patients medical conditions (Cheng, et al.). All told, the requested Velas 60w laser therapy, decompression therapy, functional neuro-ortho services, intersegmental traction, hydrotherapy, massage therapy, vibration plate therapy, and a home care instruction kit are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.