Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Generalized Body Weakness and Pain
Treatment: Outpatient Physical Therapy for 24 visits. 
The insurer denied the Outpatient Physical Therapy for 24 visits. 
The health plan's determination is upheld.

The patient is a female with diagnoses of generalized body weakness, pain and chronic fatigue (tiredness). The patient records indicate that outpatient physical therapy for 24 visits was denied as the patient has completed 22 physical therapy visits earlier this year. The patient continues to have pain with daily activities with no significant or measurable improvement in her functional level following the 22 visits. There is a to whom it may concern letter stating that the patient is being treated at this clinic for acute on chronic pain secondary to a mixed connective tissue disorder. To optimize her functionality and pain control, it was recommended that they increase the number of hours of physical therapy.
There is another to whom it may concern letter from the physical therapist stating that the patient has been under their care for general muscle weakness and low back pain and the patient has been suffering from a chronic connective tissue disease for many years and was being weaned off of Prednisone. Secondary to the process of weaning the Prednisone, the patient has chronic fatigue and it is difficult for her to perform activities or home exercises by herself. However, coming to physical therapy has been helping her low back pain and the patient feels motivated to do the exercises. Her pain has improved since she was coming to physical therapy. She was also recently diagnosed with ovarian cancer, but it was determined that she is not a candidate for a removal operation secondary to her high blood pressure. She was also sent to the emergency room (ER) twice within the past few months secondary to her extreme high blood pressure. She reported she feels depressed and completing physical therapy gives her hope.

The requested health service/treatment of outpatient physical therapy for 24 visits, is not medically necessary for the patient. According to the Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Allow for fading of treatment frequency (from up to 3 visits per week to 1 or less), plus active self-directed home physical therapy (PT). Treatment should be "active", with a formal re-assessment after a "6-visit clinical trial" to evaluate whether therapy has resulted in positive, negative, or no impact, prior to continuing or modifying treatment..."
The patient records that were provided indicate that the patient has a history of generalized body weakness and pain as well as chronic fatigue (tiredness). The patient previously had completed 22 sessions of physical therapy without any documentation of significant measurable improvement in her pain or functional capacity. The patient should have been well-versed in an independent home exercise program and it would be up to the patient to maintain motivation to participate in this home program. There is no indication for additional skilled physical therapy sessions as the patient has sufficient information to perform a home program therefore, medical necessity is not established.