Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder pain.
Treatment: Therapeutic Exercise (97110)x1, Manual Therapy (97140) x 2  and PT Evaluation (97163) x 1.

The insurer denied the Therapeutic Exercise (97110)x1, Manual Therapy (97140) x 2  and PT Evaluation (97163) x 1.  The denial is upheld. 

The records report that the patient is a female with a history of left shoulder pain for three years.  She has also had neck and mid back pain.

Three years ago, the patient visited a physician in the orthopedics department, who noted a new problem of left upper arm and shoulder pain.  She was noted to have undergone a shingles vaccine in the left arm approximately three months earlier.  Soon afterwards, she developed pain in the left shoulder and lateral upper arm.  The pains worsened over time.

A month later, left shoulder MRI (magnetic resonance imaging) was completed for an indication of left shoulder pain of two months duration with limited range of motion.  The radiologist's impressions were supraspinatus and infraspinatus tendinosis and subacromial subdeltoid bursitis.

Approximately nine months later, left shoulder MRI (magnetic resonance imaging) showed a normal rotator cuff without evidence of tear.  There was acromioclavicular joint capsular thickening.  Subacromial subdeltoid bursitis was noted.

Approximately three months later, the patient was seen in a sports medicine practice, where she complained of left shoulder pain of about one year's duration following swimming.  Her symptoms were incapacitating at times.  She had undergone "numerous injections" and had undergone physical therapy.  On examination, she was noted to have 130 degrees of forward flexion, 30 degrees of external rotation and 40 degrees of internal rotation, with pain at end range of motion.  She underwent a left shoulder steroid injection.  Physical therapy was prescribed for left shoulder bursitis and adhesive capsulitis.

Approximately three months later, the patient underwent a left shoulder steroid injection.

On telehealth visit approximately two months later with her physician, the patient was noted to have received a steroid injection into the left shoulder which relieved her adhesions over time.  She was not attending physical therapy because of the pandemic.  She was noted to have pain in the back of the shoulder and sensitivity in the front of the shoulder.  Examination was noted to show "good" shoulder flexion and motion.  The patient pointed out areas that were causing discomfort.

Approximately two months later, the patient underwent a left shoulder MRI (magnetic resonance imaging) for an indication of left shoulder pain of two years duration. The report noted findings of mild supraspinatus tendinosis with minimal burial-sided fraying.

Several days after the left shoulder MRI (magnetic resonance imaging) the patient underwent a left brachial plexus MRI (magnetic resonance imaging) which showed a normal brachial plexus.

Approximately a month later, the patient returned to physical therapy for an evaluation of her left shoulder issues.  Date of onset was listed as "8 months ago."  It was noted that she had had "extensive PT [physical therapy]," which had been "helpful," and "a cortisone shot which didn't help/increased her pain."  On examination, she was noted to be very guarded with respect to her left shoulder.  Left shoulder active range of motion was 50 degrees internal rotation, 45 degrees external rotation, 99 degrees abduction, 110 degrees flexion and 32 degrees extension.  Strength in the left upper body was rated as 3-/5.

The patient has reported that she is on "partial disability" due to her pain and shoulder issues.  She has reported a need to continue physical therapy to improve range of motion and decrease pain.

No, the Therapeutic Exercise (97110) x 1, Manual Therapy (97140) x 2  and PT Evaluation (97163) x 1 were not medically necessary.

The clinical consensus regarding treatment of stiff shoulder, frozen shoulder, or adhesive capsulitis of the shoulder has been to address etiological factors if identifiable, and to start a gentle range of motion program that progresses over time (Neviaser AS and Neviaser RJ).  The range of motion program can be started in a formal setting by physical therapists, but can be transitioned to an independent program over time.  Importantly, frequent range of motion exercise in the home setting has been shown to play a larger role in effectuating positive outcomes than the frequency of joint mobilization in a formal therapy setting.

Interventions such as steroid injections or other analgesic measures can be considered during the painful stages of initiating mobilization to expedite recovery (Page MJ, et al.; Eljabu W, et al.; Brun SP).  There is no proven marginal long-term benefit of ongoing/prolonged formal physical therapy in this clinical setting, to include interventions such as supervised exercises, manual therapy (including deep tissue work) or formal thermal modalities such as ultrasound (Page MJ, et al.).  These interventions have not been demonstrated through existing peer-reviewed, evidence-based, scientific literature to be marginally more effective for treating this condition than a compliantly followed independent exercise program with adjunctive modalities that can be independently applied as needed (e.g., topical heat).

In the present case, the patient had chronic left shoulder symptoms with reduced range of motion following a shingles vaccination shot three years prior.  She had persistent pain and functional difficulties.  She underwent extensive imaging.  She underwent extensive physical therapy.  Her symptoms and range of motion loss persisted.  As of last year, there were no proposed interventions that would have necessitated further formal therapy. At the time, she could already have been independent with a self-management program to maintain/improve range of motion, to manage pain, and to preserve functionality as able. The services in question were not medically necessary.

The patient had chronic left shoulder symptoms.  She had already undergone extensive treatment to include physical therapy.  Although she still had symptoms, no significant improvement in her course or outcomes would have been expected with further physical therapy.  She could have performed an independent program without expectation of a difference in course or outcomes in comparison to additional formal therapy.  The services were not medically necessary, and the health plan acted reasonably.