Physical Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that The patient has requested authorization and coverage for full day speech, physical, and occupational therapies performed for up to four hours per day, five days per week. Current medical literature supports the use of rehabilitation in the context of traumatic brain injury (TBI). Researchers conclude regarding the effects of physical therapy interventions on balance impairments in individuals with TBI, “The evidence about the effects of the physical therapy interventions in improving the balance ability post-TBI was limited.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for skilled nursing facility (SNF) services including physical therapy (PT) for 5 days/week x 1 hour/day until the enrollee is able to self-transfer to a wheelchair and wheels himself around, is able to self-transfer to a shower chair (and back to another chair), be able to walk on his own and be able to transfer assistance to home care; speech therapy (ST) for 5 days/week x 1 hour/day, until the enrollee is able to eat and swallow without aspiration risk (to get rid of the PEG-tube), be able to transfer assistance to home care, and speak enough to communicate and occupational therapy (OT) for 5 days/week x 30 minutes/day, until the enrollee is able to feed himself, to have control of his hands, be able to dress himself, brush his teeth and possibly be a…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy at a facility that provides weight training, has machines that test joint strength, and has an AlterG Anti-Gravity Treadmill. The current medical literature related to rehabilitation after anterior cruciate ligament (ACL) reconstruction supports early weight bearing, early range of motion exercise, and closed kinetic chain activities. As strength improves, open kinetic chain activities and more functionally advanced work can be introduced, although demanding physical activity is generally avoided during the first three postoperative months. Rehabilitation following ACL reconstruction can require be prolonged. However, the entire rehabilitation process following ACL reconstruction does not require a formal therapy setting.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy. The peer-reviewed medical literature related to rehabilitation after ACL reconstruction supports early weight bearing and range of motion exercise, closed kinetic chain activities and early mobilization (Andrade, et al.; Eckenrode, et al.). The early rehabilitation process should be closely monitored to protect against graft failure and other complications, including infection and arthrofibrosis. As strength improves, open kinetic chain activities and more functionally advanced work can be introduced, although demanding physical activity is generally avoided during the first few to several post-operative months.

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 Physical Therapy, then check the rights and deadlines that apply to your plan.