I received 6 weeks of physical therapy for a long term issue (adhesive capsulitis). My insurer determined that my care was “not medically necessary” after 6 weeks, but only started processing my claims 12 weeks after the treatment began, so I received another 6 weeks of treatment that was deemed “not medically necessary”.
My provider appealed the decision and submitted records from the beginning of treatment through the date when I received the claim denials en masse. The appeal was denied because my medical records demonstrate a slow but steady improvement during the first 6 weeks, followed by a period of plateauing (eg. minimal to no improvement) over the next 6 weeks.
My provider is a licensed DPT (Doctor of Physical Therapy) at a clinic attached to a university DPT program. My provider is a clinical faculty member at the university, and the clinic is intended to allow DPT students to gain clinical experience treating patients under the supervision of a licensed DPT.
My provider, the professor/DPT, treated me by herself during the first 6 weeks of treatment. The following 6 weeks (the plateau period that United used to determine that treatment was “not medically necessary”), I was treated by a DPT clinical student under my provider’s supervision. The claims were submitted under my provider’s name. After the student’s clinical rotation ended, I returned to the sole care of my original DPT, and my injury started to improve again.
I am currently writing a second appeal by myself, as my provider and I both agree that the physical therapy I have been receiving is in fact medically necessary for me to be able to complete everyday tasks like bathing and dressing myself (both are very hard to do with frozen shoulder, I require assistance from my partner to dress/undress). The fact that the plateau in progress ended and was followed by more improvement to my injury demonstrates that the treatment is in fact medically necessary, and that it is working!
My question is: should I mention the clinical student in my appeal letter? I can’t say for certain whether the plateau in my recovery progress was due to being under the student’s care or due to something else. My provider told me that it’s pretty common for people with my injury to see steady progress punctuated by periods of plateauing/no progress. I’m not sure whether mentioning that I was being cared for by the student (who was under my provider’s supervision – again, the claims were under my provider’s name) will help or hurt my appeal. I could see United denying this because the submitted claims are under my normal provider’s name, but the student she was officially supervising was the one actually providing care.
I also definitely welcome any other tips or advice people might have for crafting an appeal for a “treatment not medically necessary” denial or appeals related to treatment by clinical students.
tl;dr: Health insurance says that records show that treatment was ineffective and therefore not medically necessary. But the time period when treatment was ineffective was when I was being care for by a supervised clinical student! Do I mention that in my appeal?
edit: I’m not sure if location matters, but I am in Florida and my insurer is United Healthcare Student Resources.
submitted by /u/hamingo
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I received 6 weeks of physical therapy for a long term issue (adhesive capsulitis). My insurer determined that my care was “not medically necessary” after 6 weeks, but only started processing my claims 12 weeks after the treatment began, so I received another 6 weeks of treatment that was deemed “not medically necessary”. My provider appealed the decision and submitted records from the beginning of treatment through the date when I received the claim denials en masse. The appeal was denied because my medical records demonstrate a slow but steady improvement during the first 6 weeks, followed by a period of plateauing (eg. minimal to no improvement) over the next 6 weeks. My provider is a licensed DPT (Doctor of Physical Therapy) at a clinic attached to a university DPT program. My provider is a clinical faculty member at the university, and the clinic is intended to allow DPT students to gain clinical experience treating patients under the supervision of a licensed DPT. My provider, the professor/DPT, treated me by herself during the first 6 weeks of treatment. The following 6 weeks (the plateau period that United used to determine that treatment was “not medically necessary”), I was treated by a DPT clinical student under my provider’s supervision. The claims were submitted under my provider’s name. After the student’s clinical rotation ended, I returned to the sole care of my original DPT, and my injury started to improve again. I am currently writing a second appeal by myself, as my provider and I both agree that the physical therapy I have been receiving is in fact medically necessary for me to be able to complete everyday tasks like bathing and dressing myself (both are very hard to do with frozen shoulder, I require assistance from my partner to dress/undress). The fact that the plateau in progress ended and was followed by more improvement to my injury demonstrates that the treatment is in fact medically necessary, and that it is working! My question is: should I mention the clinical student in my appeal letter? I can’t say for certain whether the plateau in my recovery progress was due to being under the student’s care or due to something else. My provider told me that it’s pretty common for people with my injury to see steady progress punctuated by periods of plateauing/no progress. I’m not sure whether mentioning that I was being cared for by the student (who was under my provider’s supervision – again, the claims were under my provider’s name) will help or hurt my appeal. I could see United denying this because the submitted claims are under my normal provider’s name, but the student she was officially supervising was the one actually providing care. I also definitely welcome any other tips or advice people might have for crafting an appeal for a “treatment not medically necessary” denial or appeals related to treatment by clinical students. tl;dr: Health insurance says that records show that treatment was ineffective and therefore not medically necessary. But the time period when treatment was ineffective was when I was being care for by a supervised clinical student! Do I mention that in my appeal? edit: I’m not sure if location matters, but I am in Florida and my insurer is United Healthcare Student Resources.
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