Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy (CPT code 97110) for the enrollee to be provided by an out-of-network provider.
You asked the Plan to pre-approve the physical therapy. You say that the enrollee needs to begin these therapy sessions right away as part of the torn rotator cuff recovery. You state you have worked with the physical therapist in the past, so you know their medical history and would like to continue the care that they have already been providing. The Plan denied your request. The Plan says you did not provide records that show that the enrollee's needs cannot be met in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The provider at issue in this case is not a network provider with the Plan. 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 the physical therapy. Our physician reviewer found the requested additional therapy is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k), Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The enrollee has had extensive prior therapy and the requested additional therapy exceeds the patient's medical needs. Furthermore, there are no extenuating factors that would require this enrollee to go to an out of network provider. The additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The enrollee has had extensive prior therapy and the records do not demonstrate 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 by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the physical therapy. Therefore, we decided that the Plan does not have to pre-approve the physical therapy (CPT code 97110) for the enrollee to be provided by an out-of-network provider.