Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 59-year-old male. The patient has requested authorization and coverage for 
physical therapy, one or more areas. The Health Insurer has denied this request and reported the 
requested services are not medically necessary for the treatment of this patient. The physician 
reviewer found that the submitted documentation does not support the medical necessity of the 
requested  services.  Current  medical  literature  does  not  provide  a  consensus  concerning 
rehabilitation protocol following rotator cuff surgery, with little scientific evidence available to 
guide the timing of postsurgical rotator cuff rehabilitation. Regarding rehabilitation following 
rotator  cuff  repair,  Nikolaidou  and  colleagues  report,  Close  communication  between  the 
surgeon, the patient and the physical therapy team is important and should continue throughout 
the whole recovery process. The authors further note that protocols are commonly based on 
clinical experience and expert opinion rather than scientific rationale. In a meta-analysis of 
rehabilitation protocols after rotator cuff repair, Bandera and colleagues note that the optimum 
post-operative  rehab  protocol  remains  unclear  and  can  consist  of  either  conservative 
rehabilitation or more aggressive early range-of-motion. The authors conclude, This meta-
analysis suggests there is no clear benefit of either rehabilitation protocol when considering 
range-of-motion, with a possible benefit in functional outcome at the cost of increased re-tear 
risk post aggressive rehabilitation. Both protocols have been shown to offer safe reproducible 
short- and long-term outcomes. In this case, while a provider letter dated 9/6/22 reports that 
the patient only been approved for six physical therapy sessions, the documentation appears to 
show that the patient attended 14 physical therapy sessions for shoulder pain between 7/13/22 
and 8/29/22. In notes dated 8/18/22, the patient reported tingling in the arm, shoulder, or hand. 
As such tingling is not consistent with rotator cuff repair or injury, there is the possibility of an 
additional  pathology  that  may  be  contributing  to  the  patients  symptoms  and  functional 
limitations. Current medical literature supports a transition from skilled formal physical therapy 
to an independent home exercise program. The records do not indicate that the patient requires 
ongoing skilled therapy, and the patient has received instruction on a home exercise program. 
The  records  do  not  note  close  communication  between  the  physician  and  therapists,  as 
recommended per the literature, as physical therapy notes reported that there was no operative 
report from the physician and no protocol was provided on the prescription. In this case, given 
that the records do not support that the patient requires ongoing formal physical therapy over 
an independent home exercise program and follow-up with the treating surgeon, and as there 
appears to be a lack of communication between the surgeon and therapy team regarding the 
amount and type of therapy completed, the requested services are not medically indicated. 
Therefore, physical therapy, one or more areas, is not medically necessary for the treatment of 
this patient.