Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional electrical stimulation, therapeutic exercise and neuromuscular re-education.  You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.  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 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition. You have had a biopsy of the left thigh and both calves to assess for neuropathy. A biopsy performed on these body parts would investigate unmyelinated and thinly myelinated fibers (not large, myelinated fibers). There are no objective biopsy reports. The unmyelinated and very thinly myelinated fibers would not affect your balance. You are stated to have chemotherapy induced neuropathy; however, your medical history does not include a cancer history or history of chemotherapy use. In fact, you have multiple other conditions which could cause your symptoms including liver disease, kidney disease, sciatica, alcohol consumption, anemia, spinal stenosis with degenerative disc disease and sciatica. The systemic conditions can cause a large fiber neuropathy, which would not be assessed on a skin biopsy and could affect your balance and gait however there is no evidence of this in the documentation. The lumbar conditions could cause numbness in the feet from radiculopathy ("sciatica"). There is no evidence of a gait evaluation or a detailed neuromuscular evaluation with the evaluations of dermatomes, myotomes, reflexes, provocative spine testing. There is no evidence that you had a properly performed gait and neuromuscular examination by a physician and objective properly performed electrodiagnostic studies (EMG/Nerve conduction) through a qualified electrodiagnostic physician indicating whether your condition is a true peripheral polyneuropathy or radicular in nature from your lumbar spine conditions. Additionally, if you have large fiber neuropathy the etiology of the neuropathy can help determine the best course of treatment (i.e., eliminate alcohol or treat your liver condition or anemia.) If the condition is from your spine, you may benefit from treatment of your spine condition (i.e., spine physical therapy or injections). The current treatment you are receiving of CET and Nutra pharmaceutical injections is not the standard of care for your condition. The documentation is not clear on the true etiology of your symptoms therefore the best treatment at this time cannot be determined. The documentation currently does not reveal physical function deficits or that you need the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. 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 your 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 additional electrical stimulation, therapeutic exercise and neuromuscular re-education have not been met. Therefore, we decided that the Plan does not have to pre-approve additional electrical stimulation, therapeutic exercise and neuromuscular re-education.