Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post left rotator cuff repair.  
Treatment: Continued physical therapy. 
The insurer denied the continued physical therapy. 
The denial is upheld. 

The patient is a male who underwent left shoulder surgery for a torn rotator cuff.  The patient's understanding of his recovery was that recovery would be four to six months.  He had been instructed to start therapy soon after surgery.  He was to go to therapy three times per week.  He underwent an initial postoperative therapy evaluation with a therapy practice.  

The member had undergone 28 therapy visits.  He continued to have difficulty with various self-care and household tasks that included reaching, lifting and carrying.  He had difficulty walking his dog holding the leash in his left hand.  He had difficulty with participating in basketball and golf.  

The earliest therapy note in the records is therapy visit #29.  The patient had ICD-10 diagnoses of Z47.89 (other orthopedic aftercare), M75.112 (incomplete left rotator cuff tear or rupture), and S46.112D (long head of biceps strain).  He was performing his home exercise program but was feeling stiff.  

Therapy continued, which included therapeutic exercises, neuromuscular re-education, manual therapy and electrical stimulation.  The ensuing assessments reported that he would continue from skilled therapy services to improve activities of daily living, lifting, reaching and ambulation.  

The patient underwent 21 additional therapy visits.  

No, the additional physical therapy services were not medically necessary.  

The recovery following rotator cuff repair surgery can be prolonged.  Close therapist supervision and guidance can be helpful and important in the initial stages of a rehabilitation program following rotator cuff repair, but long-term skilled physical therapy, including supervised exercises and formal manual therapies, including manual therapy and electrical stimulation, is not generally of proven marginal benefit over an appropriate independent program.  As range of motion and strength are restored and the patient becomes accustomed to the exercises, the program can and should be transitioned to an independent program, unless there are specific documented factors that would preclude an independent program.  There is no proven benefit of formal passive manual therapy and electrical stimulation over palliative measures that can be applied independently for this condition.  Ongoing formal physical therapy is not necessarily required for the entire duration of symptoms or partial functional impairment.  

In the current case, the patient underwent rotator cuff repair surgery.  He had undergone 28 therapy visits.  He had persistent symptoms and limitations, but there were no documented impairments or other factors that would have precluded full transition to an independent exercise program.  There are no documented exercises that he was doing in therapy that he could not have done independently or substituted with independent exercise.  As noted above, there is no proven benefit of prolonged formal passive palliative modalities for the patient's condition over modalities that can be applied independently (e.g., topical heat).  Further formal physical therapy in this case would not have reasonably been expected to favorably impact the patient's outcomes or course in a clinically significant manner beyond independent exercise, self-applied modalities, and the passage of time.  The treatment in question was not medically necessary.