Independent medical review is the process where physicians
review medical cases in order to provide claims determinations for
health insurance payers, workers compensation insurance payers or
disability insurance payers. These
physicians are contracted to provide objective, unbiased
determinations on what the root cause of the treatment was, whether or
not there is medical necessity, if there was a sentinel event, what was the reason for it, etc.
Eavesdrop on some of the recent decisions which addressed whether aquatic therapy is medically necessary. Their findings might help you support your own treatment choices.
This is Part 2 of a multi-part series.
The Case: The patient is a 54-year-old female with a history of fibromyalgia and
pain in her neck, right hip, feet, knees, hands and wrists. The patient has
requested reimbursement for the aquatic therapy provided in February
2005 and prospective authorization for additional aquatic therapy. The
Health Plan has denied these requests based upon a determination that
the therapy was/is not medically necessary.
Findings: Although the patient has a chronic condition, she had not had much relief with traditional land-based physical therapy alone. A trial of aquatic therapy was reasonable and consistent with Medicare guidelines and standards within the medical community. The aquatic therapy provided in February 2005 was medically necessary and should have also included a component of patient education. Authorization for ongoing aquatic therapy is not medically necessary, as the patient should have been provided with the instruction necessary to continue her aquatic exercise program independently. Based upon the information set forth above, I have determined that although additional aquatic therapy is not medically necessary for treatment of the patient's medical condition, the therapy provided in February 2005 was medically necessary for treatment of the patient's medical condition. The Health Plan's denial should be partially overturned.
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