Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional occupational therapy visits (CPT
code 97168), for the enrollee.

You asked the Plan to pre-approve additional occupational therapy visits. You say that the enrollee needs
additional occupational therapy visits. The Plan denied your request. The Plan says the enrollee no longer
needs significant help to perform their activities of daily living. The Plan states the enrollee's caregivers have
been taught how to help the enrollee with their daily activities and therapy exercises. The Plan states the
documentation does not support the enrollee's ongoing need for the unique skills of an occupational therapist.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve additional occupational therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found based on the medical records provided
there is no documentation that the requested therapy is generally accepted as specific and effective therapy for
the enrollee's condition. Based on the available records, the enrollee appears to have improved with therapy to
the point of being able to manage their basic activities of daily living with stand-by or contact guard assistance
and they have caregivers in the long term care facility to assist the enrollee. Further skilled therapy at this point
does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional
status. Further utilization of the home exercise program and/or assistance from the long-term care staff appears
appropriate at this point. There is no documentation that the unique skills of a professional therapist are
required to safely and effectively provide treatment, that the services can be safely and effectively performed
only by a therapist or under the supervision of a therapist. Based on the available records, the enrollee appears
to have improved with therapy to the point of being able to manage their basic activities of daily living with
stand-by or contact guard assistance and the enrollee has caregivers in the long term care facility to assist them.
Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the
enrollee's symptoms or functional status. Further utilization of the home exercise program and/or assistance
from the long-term care staff appears appropriate at this point. There is no documentation that the specialized
skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program
to maintain the enrollee's current condition or to prevent or slow further deterioration. The enrollee appears to
have improved with therapy to the point of being able to manage their basic activities of daily living with
stand-by or contact guard assistance and the enrollee has caregivers in the long-term care facility to assist them.
Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the
enrollee's symptoms or functional status. Further utilization of the home exercise program and/or assistance
from the long-term care staff appears appropriate at this point.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional occupational therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve ten (10) additional occupational therapy visits (CPT code 97168),
for the enrollee.