Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke

Treatment: Physical therapy

The insurer denied coverage for physical therapy

The denial is overturned
 

The patient has a history of medullary and pontine stroke. The patient requires aggressive physical therapy (PT) and occupational therapy (OT) to regain function. The physician noted that the patient must continue PT in order to return to full function. A progress note states the patient is feeling very well and walking with her walker. The patient has been working with physical therapy with significant improvement of her hip pain, no longer falling. The patient is currently unable to support her weight only with a cane. The patient has significantly improved with physical therapy and wants to continue. No home exercise program was provided, told not to do her leg lifts. Physical examination revealed left hemiparesis and brisk reflexes. The request is for physical therapy (PT) services which is under review.

The physician noted that the patient must continue PT in order to return to full function. The request is for physical therapy (PT) services which in this case is reasonable as the patient continues to have ambulatory dysfunction and pain in the lower extremity. She is unable to do a home exercise program due to being advised not to do leg lifts and she was not provided with a home exercise program. Therefore, the request for physical therapy (PT) services is medically necessary and is approved.

"Exercise-based and brain training interventions improved functional outcomes post-stroke in low and lower-middle income countries. Further high-quality studies including participation outcomes are required. Implications for Rehabilitation: interventions requiring minimal resources can improve functional outcomes after stroke in low and lower-middle income countries. Exercise-based interventions can improve upper limb, lower limb, gait, and balance outcomes after stroke. Brain training paradigms such as mirror therapy and motor imagery, when included in therapy packages, can improve upper limb and gait outcomes. The proven efficacy for rehabilitation interventions in improving stroke outcomes in low and lower-middle income countries supports the need to strengthen the rehabilitation workforce in this context."(Dee M., et al 2018)

"Treatment should continue in the home and community settings not only for the next few to several months but even in the following years and by a variety of professional and non-professional caregivers. This care should be initiated in the early rehabilitative phase but also continue in the chronic restorative phase of life for patients living with stroke. ...maximizing functional outcome and reducing re-hospitalizations will likely further drive the care recommended by these consensus guidelines."(Burris JE., et al 2017)

"Functional task-training associated with musculoskeletal intervention and/or cardiopulmonary intervention and sensory interventions seem to be immediately effective in improving balance and postural stability, respectively."(Hugues A., et al 2019). 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for physical therapy (PT) services is substantiated.