Rehab/ Svc - Outpt denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 45-year-old female with a 20-year history of urinary urge incontinence and a more recent history of stress incontinence. She was referred to a physical therapist for treatment of her condition and indicates that progress has been made. The patient has requested reimbursement for physical therapy with biofeedback and the purchase of a pelvic floor stimulator. The Health Plan has denied these requests based upon a determination that the therapies are experimental/investigational for treatment of the patient’s incontinence.It appears from the record that the patient was not thoroughly diagnosed prior to the prescription of treatment. A consultation with an urologist, an uro-gynecologist, or possibly even a neurologist would be appropriate. Cystoscopy and urodynamic studies should be done to rule out any neurological impairment.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for therapy services (including one hour, weekly, in-person, individual therapy; one hour, weekly, in-person, family therapy; one hour, weekly, in-person, parent therapy; and one hour, weekly, 1:1 skills coaching). The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) red light therapy machine for home use, (2) ultrasound machine for home use, and (3) cold therapy unit for home use. There is limited evidence in current medical literature supporting the use of red-light therapy, also referred to as low-level laser therapy (LLLT). Childress and Beutler report regarding the management of chronic tendon injuries, “Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise.” However, Baktir and colleagues report regarding the short-term effectiveness of LLLT, “LLLT p…

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) aqua therapy three times per week for eight weeks, (2) one-on-one physical therapy two times per week for eight weeks, (3) Norco (5 mg/325 mg tablets for 60 days), and (4) dexamethasone (4 mg tablets for 60 days).Findings: The physician reviewer found that Heywood and colleagues report that it is likely that the inadequate application of resistance in water is a significant contributor to the limited effectiveness of aquatic exercise interventions in improving hip and knee muscle strength in people with musculoskeletal 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 rehab/ svc - outpt, then check the rights and deadlines that apply to your plan.