Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Physical Therapy
The insurer denied: Physical therapy services
The denial is: Upheld in whole

This is a female patient was diagnosed with left shoulder impingement syndrome and began physical therapy services.
Records provided indicate that multiple dates of physical therapy services for dates of service were denied as not medically necessary as there were no time components noted in the daily notes to support the multiple codes billed for each date for each current procedural terminology (CPT) code billed. The determination was appealed and was upheld as not medically necessary noting that physical therapy documentation requires details regarding the services including the requirement for professional one-on-one supervision to complete the activity, the time component for the service rendered, and description (type, repetitions, weights, sets, parameters, technique, etc.), as well as the area of application to support the number of CPT units billed.
There is a letter of appeal/to whom it may concern letter from the physical therapist stating the patient was being treated for adhesive capsulitis and osteoarthritis and made gains in strength and range of motion but still has decreased range of motion, strength deficits and instability as well as audible crepitus and has pain with activities. It was felt that additional physical therapy services were medically necessary to avoid surgery. The subject under review is the medical necessity for the denied physical therapy services.

The requested health service/treatment of physical therapy services is not medically necessary for this patient. Records provided indicate that the patient had chronic shoulder pain diagnosed with left shoulder impingement syndrome, adhesive capsulitis, and osteoarthritis of the shoulder. The patient was receiving physical therapy services and appeared to be progressing. However, the physical therapy documentation was insufficient to support services provided on the dates of service in question as the physical therapy notes show the therapist billing for multiple services on the same dates (billing multiple units of the same CPT codes) without documenting the time component for each of these modalities. Physical therapy documentation requires details regarding the services including the requirement for professional one-on-one supervision to complete the activity, the time component for the service rendered, and description (type, repetitions, weights, sets, parameters, technique, etc.), as well as the area of application to support the number of CPT units billed. There must be specific documentation reflecting direct one-on-one provider contact time with the patient to include total number of minutes of the service to determine the appropriate number of units to be billed. There is insufficient documentation to support the medical necessity for the manual therapy, therapeutic exercise and neuromuscular reeducation charges for the dates of service in question as there were no time components noted in the daily notes that would support billing multiple codes for each of these services. Therefore, the billed services cannot be deemed medically necessary.