This is Part 3 of a multi-part series.
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. In the past two postings on this issue, the reviewer found that aquatic therapy was necessary.
In this posting, the reviewer found that aquatic therapy was as effective as land-based therapy... but that this should lead to its denial. These findings seem capricious and ill-informed -- the reviewer state b/c there is no literature which supports the effectiveness of aquatic therapy as better than land-based therapy, that aquatic therapy should not be considered a reimbursable service. What a strange thought.
First of all, the foundational contention is wrong. There have been dozens of studies in the last 10 years which have shown that aquatic therapy offers an advantage over land-based therapy for pain and many other facets of treatment.
Second, if 2 treatment choices are equally effective -- but both are effective -- why deny one as medically unnecessary?
Read these decisions for yourself.Findings: The physician reviewer found that although aquatic therapy is certainly a choice of modality for treatment, there is no proven benefit over land-based PT in the treatment of osteoarthritis of the knee/hip. The study by Wyatt and colleagues found that both aquatic and land-based exercise programs were beneficial for osteoarthritis. Bartels and colleagues review of several studies for aquatic exercise for knee and hip osteoarthritis determined that the available studies were not conclusive to recommend aquatic therapy over land-based therapy. This reviewer did not find any published randomized, controlled trials comparing the effects of land-based versus aquatic PT for patients following TKA. Ulrich and colleagues study regarding focused rehabilitation treatment of poorly functioning TKA recommends various rehabilitation techniques, but they do not include aquatic therapy. Based on the totality of the available evidence, aquatic therapy following TKA has no proven benefit over land-based PT. Here, although this patient had improvement in ROM, aquatic therapy is not proven to be superior to traditional (i.e., land-based) physical therapy. The gains may have been made had the patient continued land-based therapy.
The Case: The patient is a 48-year-old female with degenerative disc disease and myofascial neck pain. She has been receiving physical therapy (PT) and it has apparently been helpful. The patient's provider prescribed continued physical therapy and aquatic evaluation and therapy. The patient's request for authorization of continued physical therapy and aquatic evaluation and therapy was denied by the Health Plan based on a determination that the therapies are not medically necessary.
Findings: A review of the record shows that the patient was receiving physical therapy and that it was beneficial. Some instruction in a home exercise program was provided, but the PT progress notes indicate the patient had not been fully instructed. Since land-based physical therapy was helpful to the patient, aquatic therapy would not be medically necessary at this time. The patient should continue with the land-based physical therapy in order to complete all of the instruction necessary for a home-based exercise program. Three times per week for three weeks would be a reasonable time frame. Based upon the information set forth above, I have determined one of the requested therapies is medically necessary for treatment of the patient's medical condition. The Health Plan's denial should be partially overturned.
The Case: A 45-year-old female enrollee requested authorization and coverage of
continued speech therapy, cognitive therapy, physical therapy, and
aquatic therapy. The Health Plan denied the request indicating that the
requested therapies are not medically necessary for treatment of the
enrollee's traumatic brain injury.
Findings: One physician reviewer performed a
medical necessity Independent Medical Review. The physician reviewer
partially overturned the Health Plan's denial on the basis that the
requested physical therapy is medically necessary but speech therapy,
cognitive therapy, and aquatic therapy in excess of the therapy already
approved by the Health Plan is not medically necessary.
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