Is continued physical therapy (PT) and occupational therapy (OT) medically necessary for a 54-year-old male with a history of brain lesion removal and ongoing difficulty with balance and gait?

Medical Necessity Determination for Continued PT/OT Services

Continued physical and occupational therapy is NOT medically necessary at this volume and frequency for this patient, as he has exceeded evidence-based visit thresholds without documented significant functional improvement justifying ongoing intensive rehabilitation.

Critical Issues with Current Treatment Plan

Excessive Visit Volume Without Adequate Justification

• The patient has received 90 total visits (51 PT + 26 OT + 39 previously paid) over 7 months for generalized muscle weakness and gait difficulty following brain tumor resection 1
• The Aetna rehabilitation visit table specifies 19 visits at 75% threshold for neurologic rehabilitation with diagnosis R26.2 (difficulty walking), which has been exceeded by 380% 1
• While the criteria state therapy should continue when "reasonable expectation that a member's condition will improve significantly in a reasonable and generally predictable period of time," the documentation shows plateau in functional gains 2

Documentation Fails to Support Medical Necessity

• Persistent fatigue reported as "unchanged over past few months" (DOS 8/29/25) indicates lack of meaningful progress 2
• Continued requirement for verbal/tactile cues for basic gait activities after 90 visits suggests functional plateau 2
• New rotator cuff tear diagnosis (9/8/25) represents a separate orthopedic condition, not a neurological rehabilitation issue requiring continued intensive therapy 3
• Patient continues to require "minimal to mod irritability" management and demonstrates "fair tolerance" rather than good tolerance after months of therapy 2

Evidence-Based Rehabilitation Standards

Appropriate Therapy Intensity and Duration

• Inpatient rehabilitation facilities require 3 hours daily therapy for 5 days/week with median 15-day length of stay for intensive neurological rehabilitation 1
• This patient completed 2 weeks of inpatient rehabilitation post-surgery, which is appropriate for initial intensive phase 1
• Outpatient therapy at 2x weekly for both PT and OT (4 total sessions/week) over 7 months exceeds reasonable timeframes for functional recovery 1

Expected Functional Outcomes Post-Brain Tumor Resection

• Rehabilitation services should demonstrate significant improvement in physical measures (active range of motion, strength, function) within one month of therapy initiation 4
• For pediatric CNS tumors (applicable principles for adult brain tumors), guidelines recommend rehabilitation assessment at regular intervals but not indefinite ongoing therapy 4
• Access to neuro-rehabilitation services "even years after treatment" refers to episodic care for new deficits, not continuous ongoing therapy 4

Documentation of Functional Progress

• Notes consistently describe goals as "progressing" but lack objective measures demonstrating clinically significant improvement 2
• Patient demonstrates persistent deficits requiring same level of cueing (verbal/tactile cues for gait, weight shift, knee hyperextension) throughout treatment course 5
• Fatigue remains unchanged, which is a primary limiting factor for therapy participation 6

Specific Concerns by Therapy Type

Physical Therapy (97110,97112,97530) - 51 Visits

• Therapeutic exercises and neuromuscular reeducation are appropriate interventions but should demonstrate measurable strength and gait improvements 7
• After 51 PT visits, patient still requires rolling walker with decreased step length, decreased foot clearance, and knee hyperextension requiring assistance 5
• Clonus observed with fatigue (10/19/25) indicates neurological limitation that will not resolve with additional outpatient therapy 6

Occupational Therapy (97112,97140,97530) - 26 Visits

• Manual therapy and therapeutic activities are reasonable for upper extremity weakness 4
• However, rotator cuff tear diagnosed 9/12/25 is an orthopedic condition requiring surgical evaluation, not ongoing OT for neurological rehabilitation 3
• Patient "unable to tolerate any passive abduction or flexion beyond 90 degrees" due to structural shoulder pathology, not neurological deficit 3
• Limited functional use of left hand/wrist after 26 OT visits suggests plateau in neurological recovery 3

Appropriate Transition Plan

Maintenance Program Development

• Aetna criteria allow therapy "necessary for the establishment of a safe and effective maintenance program that will be performed by the member without ongoing skilled therapy services" 2
• Home exercise program development is mentioned (9/12/25) but should have been implemented earlier in treatment course 4
• Patient should transition to self-directed exercise program with periodic reassessment rather than ongoing 2x weekly therapy 4

Criteria for Future Episodic Therapy

• New functional deficits or significant decline in established abilities would warrant re-evaluation 4
• Post-surgical rehabilitation for rotator cuff repair (if pursued) would be separate orthopedic indication 3
• Periodic reassessment (every 6-12 months) is appropriate for long-term cancer survivors, not continuous therapy 4

Recommendation

CERTIFY: 4-6 visits total (2-3 PT, 2-3 OT) for home exercise program development and transition to maintenance phase

DENY: Remaining requested visits beyond transition period

Rationale for Limited Certification

• Patient requires skilled instruction in home exercise program that he can perform independently 4
• Family education on cueing strategies and safety monitoring is appropriate skilled service 4
• Functional assessment and documentation of current baseline for future comparison 4
• Equipment evaluation (walker, adaptive devices) to ensure optimal independence 4

Clinical Justification for Denial

• Exceeds evidence-based visit thresholds by 380% without commensurate functional gains 1
• Plateau in neurological recovery evidenced by persistent deficits requiring same cueing after 90 visits 2, 6
• Fatigue unchanged over months indicates systemic limitation not amenable to additional therapy 6
• Rotator cuff pathology requires orthopedic management, not neurological rehabilitation 3
• Lack of significant functional improvement within reasonable timeframe fails Aetna medical necessity criteria 2