Is a request for 20 additional physical therapy (PT) visits, starting from 11/12/25, medically necessary for a 75-year-old male patient with a history of C3-6 laminectomy with fusion and L4-5 left hemilaminectomy, who is homebound and has functional impairments, including decreased strength, endurance, and range of motion?

Medical Necessity Determination for 20 Additional PT Visits (G0151)

The request for 20 additional physical therapy visits starting 11/12/25 is medically necessary for this 75-year-old male patient recovering from complex spinal surgery with documented functional impairments, homebound status, and ongoing progression toward therapeutic goals. 1

Justification Based on Extended Visit Criteria

Homebound Status Verification (Required)

The patient clearly meets homebound criteria as documented:

• Requires considerable and taxing effort to leave home due to impaired mobility, decreased strength, and impaired balance 1
• Needs supportive aid (assistive device documented in visit notes) to ambulate safely 1
• Shuffling gait with decreased step length/height bilaterally and lack of heel strike represents significant mobility limitation requiring skilled intervention 2

Skilled Care Medical Necessity

Complex surgical history requiring extended rehabilitation:

• C3-6 laminectomy with fusion and L4-5 left hemilaminectomy/microdiscectomy (02/09/24) 2
• Post-operative complications including hematoma evacuation (02/12/24) and cervical wound infection requiring debridement (02/24/24) 2
• This represents spinal cord injury/dysfunction meeting MCG criteria M-2255 for extended visits 1

Documented functional impairments requiring skilled PT intervention:

• Decreased strength and endurance limiting mobility-related ADLs 1, 3
• Impaired balance with documented fall risk (Tinetti Gait and Balance assessment performed) 2
• Impaired coordination and ability to transfer safely 3
• Asymmetrical, discontinuous gait pattern requiring skilled gait training 2
• Impaired ability to ascend/descend steps safely 2

Evidence of Ongoing Progress and Medical Necessity

Recent visit documentation demonstrates:

• Patient "very motivated" and "progressing toward goals" in multiple recent visits (4/7/25,4/11/25,4/14/25,8/4-8/13/25) 2
• Active skilled interventions including therapeutic exercise, gait training, balance training, muscle re-education, and functional mobility training 2
• Graded verbal cueing required for appropriate body positioning and safety, indicating need for skilled supervision 2
• Step training with variable heights for balance and strength improvement shows appropriate progression of therapeutic intensity 2

Duration and Frequency Justification

The requested 20 visits over approximately 10 weeks (2x/week) aligns with evidence-based guidelines:

• Minimum 20 sessions of comprehensive rehabilitation has been demonstrated to show considerably more improvement than 10 sessions 2
• Exercise training at least 3 times per week with regular supervision is necessary to achieve optimal physiologic benefits, though twice-weekly supervised sessions with home exercise may be acceptable 2
• Programs of 12+ weeks duration show greater, more endurable training effects than shorter programs 2
• For post-surgical spinal patients with balance impairments, 2-3 days per week of supervised training is recommended 2

Extended Visit Criteria Met

All MCG criteria for extended PT visits are satisfied:

1. ✓ Homebound requirement met (documented inability to leave home without considerable effort, requires assistive device) 1
2. ✓ Needs can be safely met with intermittent home care (patient progressing with current frequency, no complications documented) 1
3. ✓ Unanticipated functional problems impacting safe completion of mobility-related ADLs (impaired balance, gait abnormalities, fall risk, stair climbing difficulties) 1, 3
4. ✓ Evaluation and retraining of precautions required (graded verbal cueing needed for safety, ongoing balance training to prevent falls) 2, 1

Critical Clinical Considerations

Why denial would be inappropriate:

• Patient has already received 78 visits total (20+18+20+20), demonstrating complex, prolonged recovery consistent with his surgical complications 2
• Continued progression documented indicates therapeutic plateau has not been reached 2
• Premature discharge risks: Falls, re-hospitalization, loss of functional gains, and inability to maintain independence in ADLs 2, 3
• Post-spinal surgery patients require extended rehabilitation to address deconditioning, neurological impairments, and prevent secondary complications 2

Safety concerns without continued skilled PT:

• Documented fall risk with impaired balance (Tinetti assessment performed) requires ongoing skilled intervention 2
• Asymmetrical gait pattern increases fall risk and requires skilled gait retraining 2
• Stair negotiation impairment poses significant safety risk in home environment 2, 3

Recommendation

Approve the requested 20 additional PT visits (G0151) starting 11/12/25 based on:

• Clear documentation of homebound status 1
• Ongoing functional impairments requiring skilled intervention 1, 3
• Evidence of continued progress toward therapeutic goals 2
• Complex surgical history with complications justifying extended rehabilitation 2
• Patient motivation and active participation in therapy 2
• Alignment with evidence-based duration and frequency recommendations 2