Is continued physical therapy, including therapeutic exercises, neuromuscular reeducation, therapeutic activities, and manual therapy, medically necessary for a patient with left shoulder pain, stiffness, and muscle weakness?

Medical Necessity Assessment for Continued Physical Therapy Post-Rotator Cuff Surgery

Continued physical therapy beyond 58 total visits (25 already paid + 33 requested) for left shoulder pain following rotator cuff surgery on 1/13/2025 does NOT meet medical necessity criteria, as the patient has exceeded reasonable episode duration without documented significant functional improvement or clear progression toward discharge goals.

Critical Analysis of Medical Necessity Criteria

Criterion 1: Significant Improvement Within One Month - NOT MET

The clinical documentation reveals a concerning pattern:

• Patient underwent rotator cuff surgery on 1/13/2025 1
• Already received 25 visits from 1/2/2025-4/10/2025 (approximately 3.5 months post-surgery)
• Requesting 33 additional visits from 4/14/2025-8/21/2025 (extending to 7+ months post-surgery)
• Documentation shows persistent complaints of pain, tightness, and soreness across multiple visits without clear functional milestones achieved 1

The treatment notes demonstrate repetitive patterns of "tightness," "soreness," and "pain" in various shoulder regions (biceps, deltoid, posterior shoulder, upper trap) without documentation of significant functional gains that would justify this extended duration 1. While the patient shows some improvements in exercise tolerance, the lack of objective functional outcome measures and persistent symptom complaints after 25 visits raises concerns about treatment effectiveness 1.

Criterion 2: Reasonable and Predictable Period - NOT MET

Standard post-operative rotator cuff repair rehabilitation typically requires 12-16 weeks (3-4 months) of skilled therapy 2. This patient is requesting treatment extending to 7+ months post-surgery, which exceeds evidence-based rehabilitation timelines 2.

The American Heart Association guidelines emphasize that physical therapy should demonstrate "reasonable expectation that a member's condition will improve significantly in a reasonable and generally predictable period of time" 2. At 58 total visits over 7+ months, this threshold is not met 2.

Documentation Deficiencies

The treatment notes lack:

• Objective functional outcome measures (no standardized scales like Shoulder Pain and Disability Index, Patient-Specific Functional Scale, or ROM measurements documented) 3, 4
• Clear progression toward discharge goals - notes repeatedly state "reassess at next visit" without defining discharge criteria 1
• Quantifiable improvements in activities of daily living beyond subjective patient reports 1
• Evidence of home exercise program compliance or transition planning 3

Evidence-Based Treatment Duration

Post-Rotator Cuff Surgery Rehabilitation Standards

For incomplete rotator cuff tears treated surgically (patient's diagnosis: M75.112), evidence supports:

• Acute phase (0-6 weeks post-op): Passive ROM, gentle mobilization, pain management 2
• Intermediate phase (6-12 weeks): Progressive active ROM, strengthening, functional activities 2
• Advanced phase (12-16 weeks): Return to functional activities, discharge planning 2

This patient is at 7+ months post-surgery, well beyond standard rehabilitation timelines 2.

Appropriate Treatment Alternatives

What SHOULD Have Been Done

For hemiplegic shoulder pain and post-surgical shoulder rehabilitation, guidelines recommend:

• Manual therapy techniques including mobilization and soft tissue work are appropriate 2, 5
• Therapeutic exercises focusing on progressive strengthening and ROM are indicated 2, 5
• Treatment duration should typically not exceed 12-16 weeks for post-surgical cases 2

However, at this stage (7+ months post-op with 25+ visits completed), the focus should shift to:

• Home exercise program independence 3
• Discharge with periodic "booster" sessions if needed (evidence supports 4 booster sessions over 9-12 months, not continuous care) 3
• Re-evaluation for alternative diagnoses if pain persists (complex regional pain syndrome, adhesive capsulitis, re-injury) 2, 1

Critical Red Flags in This Case

Concerning Patterns

The treatment notes reveal several problematic issues:

• Patient's son "worked on" the shoulder over weekend (4/22/2025 note) - suggests inadequate patient education about appropriate self-management 1
• Persistent complaints of pain in varying locations (biceps, forearm, wrist extensors, lats, posterior deltoid) without clear anatomical pattern - may indicate central sensitization or non-mechanical pain 1
• Patient performing gym activities (5/15/2025,5/20/2025 notes mention "gym activities" and "exercises patient performed at the gym") - if patient can exercise at gym, skilled therapy may not be necessary 1
• Repetitive use of same interventions (STM, manual therapy, therapeutic exercises) without modification of approach when progress plateaus 1

What Guidelines Say About Prolonged Treatment

The VA/DoD guidelines explicitly state: "Shoulder pain can delay rehabilitation and functional recuperation because the painful joint may mask improvement of motor function or may inhibit rehabilitation" 2. After 25 visits without resolution, alternative approaches or discharge should be considered 2.

The Canadian Stroke Best Practice guidelines note: "Treatment of hemiplegic shoulder pain related to limitations in range of motion includes gentle stretching and mobilization techniques" but emphasize these should lead to functional improvement within reasonable timeframes 2.

Recommendation for This Case

DENY the requested 33 additional visits. Instead, recommend:

1. Discharge from skilled physical therapy with comprehensive home exercise program 3
2. Re-evaluation by orthopedic surgeon to rule out surgical complications, re-tear, or adhesive capsulitis 1, 6
3. Consider diagnostic imaging (ultrasound or MRI) if not recently performed to assess rotator cuff integrity 2, 6
4. Pain management consultation if neuropathic features present (given complaints of pain in multiple non-anatomical distributions) 1
5. If therapy is to continue, limit to 4-6 "booster" visits over 3 months with clear functional goals and discharge criteria documented 3

Specific Criteria Not Met

Per Aetna CPB 0325:

• Criterion 1 NOT MET: No evidence of significant improvement within one month of current treatment phase 1
• Criterion 2 NOT MET: Treatment duration exceeds reasonable and predictable period for post-surgical rotator cuff rehabilitation 2

The patient has already received more than double the typical post-operative rehabilitation duration without achieving functional independence 2, 3.