Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Physical Therapy. 
The insurer denied home visits of physical therapy. 
The denial is upheld in whole.

The patient is a female with diagnoses including  hypothyroidism acquired autoimmune, myofascial pain, hyperlipidemia, gastroesophageal reflux disease (GERD), seasonal allergies, diabetes mellitus, heart palpitations, vitamin D deficiency, sinusitis, mixed stress and urge urinary incontinence, deviated nasal septum, asthma, essential primary hypertension, constipation, anxiety and depression, urinary bladder incontinence, lumbar spinal stenosis, and hypokalemia.
There is a single progress note provided indicating the patient to have a history of multiple chronic medical conditions. It was noted she has not had a wheelchair for one month and has been approved as she is called and waiting for it. She has not been able to go out and is frustrated that hopefully she will have it in the next two days. She has significant familial hereditary spastic paraplegia. She also has other family members with the same disease. She is not very mobile and physical therapy is a significant tool to help her improve her functional state and make her a little more independent to help herself for improved function and day-to-day activities. She also follows with neurology and uses a power chair at home at times as muscles get atrophied. She has home health and also needs physical therapy. It was reported home health is increased to three times per week now. It was noted her condition is progressive. She is on multiple medications. Examination revealed no musculoskeletal exam as this was a telehealth visit. Labs were ordered and the patient would follow-up in three months.
The patient reports she also needs a physical therapist once per week to check her legs for any further damage and she then checks the range of motion and the patient states that she needs both. She reports her disorder is rare and therapy is medically necessary.
The issue under review is the medical necessity for home health visits of physical therapy. The plan partially approved the request and approved four visits, but the remaining four were denied.

The health plan's determination is upheld in whole.

The requested health service/treatment of Home health visits of physical therapy is not medically necessary for this patient. The patient is noted to have multiple medical conditions including hereditary spastic paraplegia. It was noted that the patient has been receiving physical therapy and reportedly this is beneficial to make her a little more independent and help improve her function and day-to-day activities when used as a tool. However, this appears to be maintenance therapy. There were no actual home health physical therapy notes provided indicating what specific physical therapy treatment is being performed and why the patient is not able to learn to perform these exercises and stretches independently or why she would require ongoing home healthcare therapy sessions to complete this. It appears she relies on a wheelchair for mobility. There is additionally no indication as to why this treatment needs to be completed in the home setting. Given there were no actual home healthcare therapy notes submitted documenting specific gains made or outlining specific skilled therapy needs, medical necessity of home health visits for physical therapy is not established.