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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) aqua therapy three times per week for eight weeks, (2) one-on-one physical therapy two times per week for eight weeks, (3) Norco (5 mg/325 mg tablets for 60 days), and (4) dexamethasone (4 mg tablets for 60 days).Findings:  The physician reviewer found that Heywood and colleagues report that it is likely that the inadequate application of resistance in water is a significant contributor to the limited effectiveness of aquatic exercise interventions in improving hip and knee muscle strength in people with musculoskeletal conditions. In a review of randomized controlled clinical trials of aquatic exercise compared to a control group, Bartels and colleagues conclude that there is moderate quality evidence that aquatic exercise may have small, short-term, and clinically relevant effects on patient-reported pain, disability, and quality of life in people with knee and hip osteoarthritis. In this case, the records note that the patient has undergone land based and aquatic therapy in the past. Despite being requested, there is no documentation of any objective functional improvement from the previously provided aquatic therapy to support the need for ongoing aquatic therapy, or that the patient is unable to tolerate land based therapy. As current medical literature indicates that land-based therapy is more effective at reconditioning and building strength, given the lack of adequate resistance in aquatic therapy, the requested aquatic therapy is not medically indicated. Therefore, (1) aqua therapy three times per week for eight weeks is not medically necessary for the treatment of this patient.Fritz and colleagues report that among adults with recent-onset low back pain, early physical therapy resulted in statistically significant improvement in disability, but the improvement was modest and did not achieve the minimum clinically important difference compared with usual care. Likewise, in a systematic review on the timing of physical therapy for musculoskeletal conditions, Ojha and colleagues found preliminary evidence suggesting that early physical therapy may decrease cost without compromising outcomes. In this case, the patient has undergone land based and aquatic therapy in the past. Despite being requested, there is no documentation of any objective functional improvement from the previously physical therapy to support the need for ongoing therapy. Further, there is no documentation of recent functional deficits that would be unable to be addressed with a home exercise program but would be expected to improve with additional therapy. Therefore, (2) one-on-one physical therapy two times per week for eight weeks is not medically necessary for the treatment of this patient.On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues note that clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety, and that clinicians should review the patients history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every three months. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs. Rosenberg and colleagues highlight avoiding opioid therapy longer than 90 days as a critical juncture. In this case, while the records document Norco use, there is no documentation of pain reduction or functional improvement from the use of Norco, or of regular monitoring as recommended by guidelines. Therefore (3) Norco (5 mg/325 mg tablets for 60 days) is not medically necessary for the treatment of this patient.The U.S. Food and Drug Administration (FDA) notes that the use of dexamethasone is indicated for allergic states, dermatologic diseases, endocrine disorders, gastrointestinal diseases, hematologic disorders, neoplastic disease, nervous system, ophthalmic disease, renal disease, respiratory diseases, and rheumatic disorders. El-Darouti and colleagues report that compared with daily steroid dosing, weekly oral steroid pulse therapy induces no significant bone loss and no suprarenal suppression and can be an alternative option in the treatment of chronic disorders requiring long-term oral steroid therapy. In this case, the records did not include documentation of a diagnosis for which this medication is indicated. Further, the records did not include a discussion indicating that the benefits of the medicine may outweigh the risks, given that this medication has a substantial risk for worsening blood sugar control in diabetics. Therefore, (4) dexamethasone (4 mg tablets for 60 days) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services and medication 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 with sub-specialty certification in pain medicine 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.