Diagnosis: Shoulder pain, cervical radiculopathy, chronic low back pain

Treatment: Additional Physical Therapy Services

The insurer denied coverage for additional physical therapy services. The denial was reversed.

This patient has a past medical history of diabetes mellitus type 2, degenerative joint disease (with previous bilateral total hip replacement), renal stones and asthma and who has been seen in physical therapy for right shoulder pain, cervical radiculopathy and chronic low back pain. Per the physical therapy progress note, the right shoulder pain was a 10/10 and described as sharp, constant and aggravated by overhead movements and relieved by rest. Low back pain was an 8-9/10 and described as throbbing, constant and aggravated by sitting and relieved by side-lying. The patient did not have pain improvement with cyclobenzaprine and acetaminophen. The patient was improving with physical therapy; however, the patient had to attend to family issues for two weeks. The patient had an exacerbation of symptoms with increased stiffness and lack of motion. Per physical therapy note three weeks later the patient was seen for right shoulder pain and low back pain. Pain was a 6/10. Since the last visit, the patient received an intra-articular corticosteroid injection into the right shoulder. The patient reported the pain was improving and the patient was able to do more with physical therapy.

The patient completed at least 25 physical therapy visits. The patient's pain had decreased from a 10/10 to a 6/10. While the patient did have some decreased range of motion to the right shoulder, the patient's recent cortisone injection to the right shoulder was providing significant pain relief, which allowed the patient to do more physical therapy exercises. The patient previously had improvement in pain and range of motion in the lumbar spine with physical therapy. Therefore, additional physical therapy visits would be appropriate. As such, the additional physical therapy services are medically necessary, and the prior determination is reversed.