Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve electrical stimulation services and additional physical therapy 
visits. 
 
You asked the Plan to pre-approve electrical stimulation services and additional physical therapy visits. You 
say that the services were requested by your doctor and are supported by the records provided. The Plan denied 
your request. The Plan says that the service in dispute is not covered by Medicare. 
 
The Local Coverage Determination (LCD) that the Plan used in making their determination regarding electrical 
stimulation services does not apply to the services being requested. This is because the enrollees treatment is 
not for peripheral neuropathy.  
 
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 electrical stimulation services and 
additional physical therapy visits. Our reviewer says that the criteria for coverage have been met. Our physician 
reviewer found the enrollee has radiculopathy in the lumbosacral region. The enrollee underwent initial 
physical therapy evaluation and certification on June 20, 2022. The treatment plan parameters were 3 visits per 
week for 4 weeks. On July 8, 2022, the parameters were the same. Good symptom relief with therapy was 
reported. On July 18, 2022, the parameters were the same. On August 5, 2022, the parameters were the same. 
The enrollee was progressing session to session as expected, indicating stability of symptoms and efficacy of 
the treatment plan. The enrollee got good symptom relief with treatment. Decreased external rotation strength, 
hamstring flexibility, and transverse abdominus neuromotor control indicated need for continued skilled 
physical therapy. Physical therapy is generally accepted as specific and effective therapy for lumbosacral 
radiculopathy. The documentation does support 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 for physical therapy and occupational therapy, by or under the supervision of a therapist. It is not 
documented that the requested services are part of a maintenance program. The enrollee should be able to continue with the plan of care, which has included electrical stimulation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electrical stimulation services and additional physical therapy visits have been 
met. Therefore, we decided that the Plan has to pre-approve electrical stimulation services and additional 
physical therapy visits.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.