Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Scoliosis.
Treatment: Physical Therapy (schroth method).
The health plan denied Physical Therapy (schroth method). 
The denial is upheld.

The patient is an adult female with a history that includes neck spasm, back pain, lumbar disc herniation, sciatica, juvenile idiopathic scoliosis, asthma, arthralgias, myalgias, "chronic Lyme" disease, and hyperlipidemia. She is reported to have had some plain films that were "all fine." It is reported that she has not had a scoliosis imaging series. She has been undergoing physical therapy since last Autumn. It is reported that she has been making "slow progress" with physical therapy applying the Schroth method. It was opined that she needs another 24 weeks (72 visits) of Schroth physical therapy.

The health plan denied coverage of the service under review, indicating that the service is not medically necessary based on the available documentation, which was reviewed and found to show no progress. The denial is being appealed.

Many different treatment modalities have been employed over the years with an aim of altering the natural history of juvenile and adolescent idiopathic scoliosis, including braces, manual therapy, chiropractic, shoe inserts, and physical therapy. Physical therapy includes general therapy interventions, as well as scoliosis-specific methodologies, including the Lyon approach, Schroth method, SEAS (Scientific Exercise Approach to Scoliosis) method, Barcelona Scoliosis Physical Therapy School method, Dobosiewicz method and Side-shift exercise program (Berdishevsky H, et al., 2016; Day JM, et al., 2019). While scoliosis-specific exercises are often recommended for this condition, there is a dearth of evidence from high quality studies that establishes a benefit of these various methods with respect to outcomes such as scoliotic curve progression (Romano M, et al., 2013; Plaszewski M and Bettany-Saltikov J, 2014; Day JM, et al., 2019). A systematic review by Day JM, et al. (2019), noted a lack of compelling evidence that any scoliosis-specific physiotherapy methodology (including the Schroth method), was more effective than observation/no intervention or general exercise in reducing scoliotic progression. Day JM, et al., also noted a lack of published investigation comparing any of the scoliosis-specific physiotherapy methodologies to one another. The evidence base that supports these methods is largely composed of data from low quality studies with high risk of bias. The studies that support the Schroth method, for instance, have largely been published by the directors of rehabilitation centers that promote the use of this methodology.

The effectiveness of nonsurgical interventions, including bracing and scoliosis-specific physiotherapy, to objectively alter disease course in juvenile or adolescent idiopathic scoliosis is, on the whole, unclear (Plaszewski M and Bettany-Saltikov J, 2014; Day JM, et al., 2019). When the pathology progresses and palliative, compensatory and other conservative measures fail to adequately address the functional and health-related quality of life concerns, surgical interventions, including extensive spinal reconstruction, are generally recommended to be considered.

In the present case, the patient's scoliotic curves are not described in detail, e.g., curve angles. She has been empirically undergoing physiotherapy utilizing the Schroth method of scoliosis-specific physiotherapy for symptoms attributed to her scoliosis without clinically significant benefit. Given the lack of clinical benefit of the empirically administered therapy and the lack of objective evidence supporting the effectiveness of the Schroth method of scoliosis-specific physiotherapy, particularly in the setting of scoliosis in the patient's age group, the service in question is not medically necessary. The health plan appropriately denied coverage of the requested service.