Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic weakness
Treatment: Additional physical therapy (PT) x 12 visits 
The insurer denied coverage for additional PT x 12 visits.
The denial is overturned.

This case involves an elderly patient diagnosed with chronic obstructive pulmonary disease, generalized muscle weakness, other abnormalities of gait and mobility, difficulty walking, history of falling, spinal stenosis of the lumbosacral region, and primary osteoarthritis of an unspecified shoulder. The patient was seen for a PT initial examination. The report stated the patient was doing well until she contracted the Coronavirus disease 2019 (COVID-19) virus. She was hospitalized for 2 days and then sent home reporting that a few PT visits without good results. She felt better overall but continued to have weakness over the legs and arms with limited walking. The patient lives in a private home with a 24/7 awake caregiver who assisted the patient with activities daily living such as dressing, bathing, meal prep, cleaning, and laundry. The patient had limited walking with a rolling walker and had a fear of falling. Her pain level range between 5-7/10. Objectively, vital signs were stable. She required max assist with supine to sit, moderate assist for sit to stand, with strength in the lower extremities graded 3+/5 throughout. The assessment indicated the patient was referred for skilled PT evaluation with claims her prior level of functioning was independent with a rolling walker in the home. She presented with decreased/declines in muscle strength, transfers, standing, balance, and safe ambulation. Recommendation was for skilled home PT 1-3 times a week for 12 weeks to improve her functional mobility. A written home exercise program was reviewed and given. The patient was seen for follow up. She had completed 12 sessions of PT at that point in time with her pain level 3/10. She still required max assist for supine to sit transfers with only minimal assist for sit to stand. She had a shortened stride length and ambulating with a rolling walker. Muscle strength had slight improvement. The assessment indicated that there were improvements noted with muscle strain, standing balance with assistive device (AD), and safe ambulation. Improvements were noted by the patient's aide in terms of getting into and out of the shower daily. The recommendation was for ongoing PT 1-3 times a week for 12 weeks. The patient received a notice of adverse determination stating that the patient was able to walk forward and independently with a Rollator walker up to 180 feet while someone is holding her up.  She was able to change positions from sitting to standing with minimal help and could continue doing a home exercise program.  

Medical literature notes that falls account for one of the most common and serious issues contributing to a disability, especially among elderly individuals. Records noted the patient continued to have chronic weakness following contraction of COVID-19 early this year. She still had difficulty transferring from a supine position to a sitting position and while she had minimal improvements with sit to stand transfers, she continued to have moderate weakness in the lower extremities, which increases her risk for falls. In taking the patient's age into consideration, additional PT would be reasonable as she had made improvements but would not likely have as rapid recovery as a younger patient may have in a similar condition. Therefore, to assist in returning the patient to her prior level of functioning while reducing her risk of falls and potential injuries, the additional PT x12 visits is supported.   

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for additional physical therapy (PT) x 12 visits is overturned. Medical Necessity is substantiated.