Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for outpatient vestibular (physical therapy) twice a week for eight weeks (CPT 97163  physical therapy evaluation high complex; 97162  physical therapy evaluation mod complex; 97110  therapeutic exercises (including ROM, flexibility, endurance); 97112  neuromuscular re-education)); and outpatient speech therapy (cognitive speech therapy) twice a week for six weeks (92522  evaluation speech; 96125  cognitive performance test; 97129  therapy interventions/focus on cognition 30 minutes; 97130  therapy interventions/focus on cognition additional 15 minutes). As noted in the medical literature, most patients recover from concussions within two weeks and the persistence of symptoms beyond the generally accepted timeframe for recovery is referred to as post-concussion syndrome (Leddy, et al.). The mainstays of treatment for concussion and post-concussion syndrome are an early period of relative rest with gradual return to activities and self-management strategies. Some rehabilitation interventions in the early setting have been shown to be effective in addressing functional concerns for this condition, but there is a lack of data in the peer-reviewed medical literature demonstrating the effectiveness of individualized rehabilitation for post-concussion syndrome, particularly in the long-term (Jaber, et al.). Well-conducted trials are required to determine what types of treatment, if any, are effective beyond a placebo effect (Heslot, et al.). In this case, the patient presents with chronic, persistent symptoms following mild TBI. The patient has exhibited decreased activity tolerance, which has required activity modification. Also noted are mild issues in the mental health domain that have improved with counseling. Although the patient has multiple ongoing symptoms, there is a lack of support for the proposed therapy to provide any clinically significant benefit. Accordingly, the requested outpatient vestibular (physical therapy) twice a week for eight weeks (CPT 97163  physical therapy evaluation high complex; 97162  physical therapy evaluation mod complex; 97110  therapeutic exercises (including ROM, flexibility, endurance); 97112  neuromuscular re-education)); and outpatient speech therapy (cognitive speech therapy) twice a week for six weeks (92522  evaluation speech; 96125  cognitive performance test; 97129  therapy interventions/focus on cognition 30 minutes; 97130  therapy interventions/focus on cognition additional 15 minutes) are not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.