Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral shoulder pain.
Treatment: Occupational Therapy - 6 visits.
The insurer denied the Occupational Therapy - 6 visits.
The denial is upheld.

The records report that the patient is a female with a history of bilateral shoulder pain and stiffness.  The onset of her symptoms was earlier this year, with no preceding trauma.  She was diagnosed with bilateral shoulder adhesive capsulitis.  She also has a chronic history of a herniated disc in the neck.  She is a reported to be a day care teacher.

The patient was seen for a therapy evaluation two months later.  She had undergone a left shoulder steroid injection two weeks earlier, without improvement.  On examination, active range of motion at the left shoulder was 120 degrees flexion, 120 degrees scaption, 75 degrees abduction, 50 degrees extension, 40 degrees external rotation (neutral position), and 30 degrees internal rotation (neutral position).  Active range of motion at the right shoulder was 150 degrees flexion, 150 degrees scaption, 90 degrees abduction, 50 degrees extension, 35 degrees external rotation (neutral position), and 45 degrees internal rotation (neutral position).  Passive range of motion at the shoulders was mildly better than active range of motion.  Strength at the shoulders was rated to be in the poor minus to fair minus range.

The patient underwent a therapy program that included exercises, manual therapy and topical thermal modalities.

The patient had undergone 12 therapy visits.  She had difficulty with functional activities.  The therapist reported that she had made "slight progress" with active and passive range of motion at the bilateral shoulders.  She had "extreme pain limiting independence."  Active range of motion at the left shoulder was 125 degrees flexion, 125 degrees scaption, 80 degrees abduction, 55 degrees extension, 45 degrees external rotation (neutral position), and 35 degrees internal rotation (neutral position).  Active range of motion at the right shoulder was 150 degrees flexion, 150 degrees scaption, 90 degrees abduction, 50 degrees extension, 35 degrees external rotation (neutral position), and 45 degrees internal rotation (neutral position).  Passive range of motion at the shoulders was mildly better than active range of motion.  Strength at the shoulders was rated to be in the poor minus to fair minus range, without change versus approximately two months prior.  Grip strength was mildly improved.

The patient underwent an intra-articular steroid injection of one or both shoulders (unspecified in the records).  Therapy continued.

Approximately a month later, the patient was seen in follow up by her physician and noted to have had "slight evidence of improvement."  She was noted to still have "marked dysfunction of her shoulders."  On examination, she was reported to have 5/5 strength at the bilateral shoulders.  The shoulders were deemed to be "stable," without alignment abnormality, deformity or tenderness.  Left shoulder passive forward flexion was 90 degrees, limited further by severe pain.  The right shoulder could be forward flexed to 110 degrees.  Rotation was limited bilaterally.  Further therapy was recommended. 

The patient has reported that she feels she would not be able to return to her pre-pandemic job without more occupational therapy.

The health plan approved coverage of four occupational therapy visits from, denying coverage of the remaining therapy visits.  It was noted by the health plan that the patient's condition had not changed significantly since care started and that the notes did not show that the skills of a therapist were needed.

No, the services in question were not medically necessary.
The clinical consensus regarding treatment of stiff shoulder, frozen shoulder, or adhesive capsulitis of the shoulder has been to address etiological factors if identifiable, addressing pain to allow for range of motion, initiation of a gentle range of motion program, and progression of the program over time (Neviaser AS and Neviaser RJ,; de la Serna D, et al.).  The range of motion program can be started in a formal setting by physical therapists, but can be transitioned to an independent program.  Importantly, frequent range of motion exercise in the home setting has been shown to play a larger role in effectuating positive outcomes than the frequency of joint mobilization in a formal therapy setting.

Interventions such as steroid injections or other analgesic measures can be considered during the painful stages of initiating mobilization to expedite recovery (Page MJ, et al.; Eljabu W, et al.; Brun SP).  There is no proven marginal long-term benefit of ongoing/prolonged formal physical therapy in this clinical setting, to include interventions such as supervised exercises, manual therapy (including deep tissue work) or formal thermal modalities such as ultrasound (Page MJ, et al.).  These interventions have not been demonstrated through existing peer-reviewed, evidence-based, scientific literature to be marginally more effective for treating this condition than a compliantly followed independent exercise program with adjunctive modalities that can be independently applied as needed (e.g., topical heat).

In the present case, the patient had been undergoing therapy for adhesive capsulitis of the bilateral shoulders without documented significant functional or other clinical benefit.  Despite the formal therapy she underwent, she continued to have symptoms, with decreased range of motion and weakness at the shoulders.  There was, nonetheless, no documentation of exercises or services that could not have been transitioned to independent exercises or modalities.  No marginal benefit would have been expected with prolonged formal exercises or manual therapy for her conditions over a compliantly followed independent program.  The additional six visits in question are not medically necessary.

The patient had persistent shoulder symptoms.  She had already undergone sufficient therapy to have been trained in an independent program to improve her range of motion, strength and function.  Although she still had symptoms, no significant improvement in her course or outcomes would have been expected with further occupational therapy.  The services were not medically necessary and the health plan acted reasonably.  The health plan appropriately denied coverage of the additional therapy visits in question given that the patient's condition had not changed significantly since care started and given that the notes did not show that the skills of a therapist were needed on an ongoing basis.