EK HEALTH

by David Ehrenfeld, MD
EK Health Services' Director of Medical Quality Assurance

“Physician Reviewer’s Rationale” is separate from “Treatment Guidelines Used”.  Rationale is a terse synopsis/synthesis of the clinical and historical factors. It explains the “Why?” of the Recommendation; it is the connection between the Treatment Guideline(s) used and the Recommendation.  This is of importance and value to the insurer as well as the requesting physician, and perhaps even a Workers’ Compensation judge at a later date.

One example would be where there was request for more PT beyond the amount suggested by the guideline that would be quoted later in the report. This instance would be while analyzing the case, you see that the worker had not shown significant improvement with the first 5 visits of PT but after visit 7 of 8 had documented significant improvement in both expression of decreased pain AND documented increases in ROM, lifting etc.. whereas for this hypothetical case 10 visits over 8 weeks would be the cited ODG guideline,

Rationale to Certify

RECOMMENDATION

CERTIFY additional PT x 4

RATIONALE: An additional PT X 4 is medically reasonable based on the documented, albeit slower than expected, improvement.

On the flip side might be request for 4 more PT where it is submitted that all goals have been met with restoration of full range of motion and unlimited lift/reach.

Rationale to Non-Certification

RECOMMENDATION

Non-Certification additional PT X 4

RATIONALE: Reports document 9 PT visits to date with full functional recovery and with return to full duties. There is no submitted basis upon which certification of additional PT would be needed.

GUIDELINE USED:

1.   CA MTUS 2009 ACOEM Guidelines 2004 2^nd edition, chapter 9 Shoulder Complaints does not address amount nor frequency of PT for condition XYZ.

2.   ODG cites PT 10 visits over 8 weeks for rotator cuff strain