Aquatic Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for aquatic therapy once weekly. At issue is whether aquatic therapy once weekly is medically necessary for the treatment of this patient.In this case, the patient has chronic low and mid-back pain. She has tried different medications and injections with some relief. Additional treatment has included aquatic therapy, which, as the documentation indicates, objectively improved the patient’s range of motion, strength, and endurance. The patient is noted to have fibromyalgia. A randomized controlled trial concluded that aquatic therapy was better than land-based therapy for reducing pain intensity and improving sleep quality for women with fibromyalgia. A systematic review and meta-analysis concluded that water therapy can benefit such patients by reducing disease activity and alleviating pain.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for aquatic therapy. Aquatic therapy is a form of exercise therapy which minimizes the effect of gravity and is beneficial for patients with morbid obesity and osteoarthritis who would otherwise not be able to exercise due to pain and excessive body weight. Researchers concluded that aquatic-based exercise generate a different exercise outcome and appear to provide an alternative option for older aged adults, allowing these tasks to be performed in a manner that is not possible on land. Land based physical therapy is difficult for morbidly obese patients. As such, the requested aquatic therapy is medically necessary for treatment of this patient’s medical condition.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Aquatic Therapy.Exercise in an aquatic setting is one of several options for exercise that can potentially provide symptom relief for various pain conditions (Verhagen, A., et al.; Baena-Beato, P., et al.). It is thought that the warmth and buoyancy of water may help block nociception by acting on thermal and mechanoreceptors, thus influencing spinal segmental mechanisms (Kamioka, H., et al.). The evidence-based literature, nevertheless, has not demonstrated that aquatic exercise is an effective intervention for back pain overall (Kamioka, H., et al.; Morelhão, P., et al.). There are no proven or expected marginal benefits of formal aquatherapy programs over water-based exercises that are pursued independently or performed in informal group exercise settings.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for aquatic therapy services consisting of 12 additional 30-minute sessions twice a week for six weeks. The records provided for review document that this patient is status post right hip hemiarthroplasty for a hip fracture after a fall in 2021. The provider noted that the patient has undergone extensive physical therapy. The patient has participated in aquatic therapy and she has been educated on a home exercise program. The patient has requested additional aquatic therapy services. As noted in the medical literature, exercise in an aquatic setting is one of several options for lower intensity exercise that can provide a more tolerable environment for exercise, as well as symptom relief for patients with various health conditions.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Aquatic Therapy, then check the rights and deadlines that apply to your plan.