Fighting therapy denial

A reader sent me this on how he successfully challenged the denial of therapy. You may want to not always point to my blog as it can be quite profane. But do refute their assumptions about plateau and recovery. You'll have to refute each point they bring up. Good luck.

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Lifewise Therapy Denial of Providence Occupational Therapy Complaint
Jacob L. Heller, MD, MFIA
Assistant Medical Director
Regarding the letter dated 08/17/15, denying coverage for
the additional OT requested by Providence, it states
“your contract does not provide for Outpatient Rehabilitation Extension”.  I reviewed and disagree for these reasons:
1.   For my policy, LifeWise Exclusive Provider Bronze 5250 HSA, your sales department puts out this brochure https://www.lifewiseor.com/documents/027825.pdf
In section #7 it clearly states(additional 30 visits available for neurological conditions)
I picked this policy and entered into the contract with Lifewise because of this sentence.
2.  This is repeated in more detail on page 5 of the actual Policy Booklet
Rehabilitation Limited to a combined 30 outpatient visits and a combined 30 inpatient days per Year. An additional 30 outpatient visits will be allowed for stroke.
3.   Notice it says “will be allowed for stroke” with no qualifiers.  I cannot imagine anyone at Lifewise could even open my file and not know I had a stroke on 5/04/13 with continuous rehab since then.  However, they definitely would have noticed Lifewise has paid out $343,000 since my stroke, and systematically look for ways to deny more expenses.
A few days later, I received the letter dated 08/20/15, denying coverage for the additional OT requested by Providence.  It states “During maintenance therapy, improvement is no longer occurring or is not expected to occur.”  I reviewed and completely disagree for these reasons:
1.   This is often called a plateau, which is not a medical term, but a term used by insurance companies to limit therapy and save money using it as an excuse to discontinue payment for treatment and say the patient has plateaued.
a.   Follow this links to see a sampling of publications (10 ) that documented that recovery is possible and even likely, if the survivor is willing to work at it:
http://oc1dean.blogspot.com/search/label/plateau
b.   This link directly addresses 'Plateau' is a term frequently used in relation to decisions to discharge patients from physiotherapy following stroke.
http://oc1dean.blogspot.com/2011/04/plateau-bad-word-in-stroke-recovery.html
c.    This link is a compilation of documents by Peter G. Levine is co-director of the Neuromotor
Recovery and Rehabilitation Laboratory (rehablab.org) and the author of
Stronger After Stroke (best book I have found)
http://recoverfromstroke.blogspot.com/search?q=insurance
d.   In the 28 months since my stroke on 05/04/13, I have never plateaued, or ever lost function once gained. No doctor or therapist has ever said I could not get better, if I follow their directions and diligently work at it, which I do.  Of course, most will not predict how much more improvement could be achieved or how long it would take, but if anyone can improve, I can and have continuously.  In fact, my physiatrist once told me if he had a stroke, he hopes he would approach rehab the way I do.  All of my therapists tell me I am one of their best patients, because I do what they prescribe and I am getting results.  But recovery from 100% hemiparesis it is painful, difficult, slow, and time consuming, & complicated process.  I am very determined to improve and the gains I have achieved are what keep me working on rehab.
2.   Everyone should exercise to “maintain” their health.  The Mayo Clinic recommends at least 30 minutes a day
http://www.mayoclinic.org/healthy-lifestyle/fitness/expert-answers/exercise/faq-20057916
  I average 8 times that everyday so I can continue to improve, which is way beyond “maintenance”.  I need expert advice from therapists periodically to maximize my recovery efforts & results.
3.   There is no “magic bullet” to repair the brain damage from a stroke, but the neuroplasticity of the brain allows a survivor to drive recovery by rewiring the brain.  This often takes thousands of repetitions, done with intention, to establish new neuro pathways and muscle memory to replace the ones in the dead area. 
The brain, and how it works and controls motion, is not well understood, but the medical community is trying hard to find ways to cause, speed up, and focus this process for stroke recovery.  Here is a link to 240 stroke neuroplasticity related documents:
http://www.oc1dean.blogspot.com/search/label/neuroplasticity
4. There are millions of brain injury survivors like me and the medical community is working hard to solve the problems of stroke, but it is a very complicated & tough problem.  I do not expect anyone to read all this, but here is a link to 122 documents related to the problems of stroke:
http://oc1dean.blogspot.com/search/label/problems%20in%20stroke
Excuse the language in it, but I do think every stroke survivor & provider should read this summary:
http://www.oc1dean.blogspot.com/2014/10/all-fcking-problems-in-stroke.html
5.   There are a bewildering amount of theories, methods, devices, and treatments being investigated & tried.
Knowing the insurance companies will not pay for anything new, my providers have advised me to stay with conventional OT & PT to avoid unnecessary expense & frustration.
The letter dated 08/20/15 also states “We based this decision on your healthcare plan, on our criteria Policy 8.03.503 - Occupational Therapy and review of the information given to us by Providence Portland Medical Center 
I found the medical policies referred to in your letter at:
Policy 8.03.503 - Occupational Therapy
https://www.lifewiseor.com/medicalpolicies/CMI_052855.pdf
Policy 8.03.502 - Physical Therapy 
https://www.lifewiseor.com/medicalpolicies/CMI_051155.pdf
I am including the PT Policy also, since I need to continue both OT & PT and obviously the treatment and issues overlap.  I have not seen a response to request for additional PT from Therapeutics & Associates on 08/20/15, but I assume it will be treated the same way.
September 3, 2015

Lifewise denial of Therapy request
2015-09-03 Lifewise Therapy Denial Complaint Letter
Each policy starts with this: OT/PT may be considered medically necessary when ALL of the following criteria are met:
1.   The patient has a documented physical functional impairment or disability due to disease, trauma, congenital anomalies, or prior therapeutic intervention AND
2.   The patient has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time based on specific diagnosis-related treatment/therapy goals AND
3.   The OT service is delivered by a qualified provider of OT services AND
4.   Due to the physical condition of the patient, the complexity and sophistication of the therapy and the therapeutic modalities used; the judgment, knowledge, and skills of a qualified OT provider are required.
I am not a doctor, just the patient, but I can read a contract, and submit the following substantiated reasons these 4 criteria of “Medical necessity” in OT & PT policies apply to me:
1. Documentation criteria: I have a very well documented brain injury, caused by a stroke on 05/04/13 caused by Whipples disease (bacterial infection)
resulting in 100% hemi-paresis of non-dominant left side of whole body. High tone & spasticity developed
a.   I have most of my medical records, which are hundreds of pages, and more than any doctor or therapist has time to review it.  It is a long story, and I get tire of repeating it, so for my own
understanding, and the benefit of my providers, I prepared the attached

2.
The 2nd clause looks like it was written by a lawyer, who invariably parse sentences like this, so I will also:
a.   The word “reasonable” is used in contracts when something is hard to define and subject to
opinion.  Obviously, we will never agree on what is reasonable and will have to rely on the opinion of doctors.  If they cannot agree, we will have to get an opinion from the Oregon State Insurance Commission.
b.   This sentence works well for something orthotic and isolated to a specific part of the body.  It does not work well for something as systemic and neurologic as a stroke.  In the big picture, I do not have a nerve, joint, or muscle problem, I have a brain problem.  The only real cure is to form new neural pathways in the healthy parts of my brain to connect and control my muscles again--neuroplasticity discussed above.
c.    My “expectation” is I will continue to improve, because that is my experience, and has become my primary goal.
i.   I realize, the odds are not in my favor, since I did not have much spontaneous recovery
early on.  The following info is from NIH http://www.ninds.nih.gov/disorders/stroke/stroke_rehabilitation.htm
ii.   According to the National Stroke Association (NSA):
1.   10% of stroke survivors recover almost completely
2.   25% recover with minor impairments
3.   40% experience moderate to severe impairments that require special care
4.   10% require care in a nursing home or other long-term facility
5.   15% die shortly after the stroke
6.   Approximately 14% of stroke survivors experience a second stroke in the first year
following a stroke. I am currently in the 40% group and “reasonably” “expect” to get into the 25%
group.  I am hopeful I will eventually into the 10% group.
iii.   Per NSA successful rehabilitation depends on:
1.   Amount of damage to the brain
2.   Skill on the part of the rehabilitation team
3.   Cooperation of family and friends. Caring family/friends can be one of the most
important factors in rehabilitation
4.   Timing of rehabilitation – the earlier it begins the more likely survivors are to regain
lost abilities and skills
Oddly, they did not mention the health, smarts, & will power of the survivor,
which I think sets me apart from the average survivor.
iv.   Comments on rehab factors:
1. The brain damage is what it is. 2.1 x 4.0 cm per CT & MRI.  See medical records
for details.  I am fortunate the brain damage did not affect cognition, memory,
emotions, speech, swallowing, etc.
2. Skill of team: I have a generally had good care throughout this ordeal, and have a
great neuro rehab team right now.
3. Support: I have an awesome family and support system cheering me on!
4. Timing of rehab:
a.   In the acute phase I was wiped out by the Whipples, which is 100% fatal if
not diagnosed in time.  Since I was so weak, from losing 40 lbs. in 4
months, then having a stroke, it took weeks to recover enough to even
attempt inpatient rehab at Rehabilitation Institute of Oregon (RIO)
b.   In 2013 Lifewise only allowed 8 days, which I now know was inadequate.  I
surmise Lifewise knows this now also, since current policy allows 30 days
inpatient. RIO was at the end of my 56 days in the hospital, when I was
discharged to go home in a wheelchair 06/28/13.
c.    Then, Lifewise allowed 8 weeks of home therapy before being discharged
08/28/13 to begin outpatient sessions.  This was probably the sub-acute
phase when I could only walk a short distance with a quad cane & AFO,
and my left arm & hand was useless.  I was having a lot of pain and
weakness on my whole left side at that time.  Very hard & painful to stand
or sit up straight, because tightness on left side of trunk pulling me down.
Research shows this is a critical period to do rehab with repetitions & intensity as high as possible.  3 or 4 hours a week is not even close.
d.   So early rehab did not happen for me
e.   Since I am not a doctor, I can’t say when I would be classed in the chronic
stage, but that is where I am in now. Again, I am just the patient, but the above is why I “reasonably expect” additional recovery even in the chronic phase.
d. Achieving:
I used to ask every provider “Where am I along the path to recovery?”
i.   In reality, no one really knows, and they are reluctant to guess, because the truth is vague
& discouraging. But, the Brunnstrom Approach follows six proposed stages of sequential
motor recovery after a stroke.
https://en.wikipedia.org/wiki/Brunnstrom_Approach
Stage
Description
1. Immediately following a stroke there is a period of flaccidity whereby no movement of the limbs on the affected side occurs.
2. Recovery begins with developing spasticity, increased reflexes and synergic movement patterns termed obligatory synergies. These obligatory synergies may manifest with the inclusion of all or only part of the synergic movement pattern and they occur as a result of reactions to stimuli or minimal movement responses.
3. Spasticity becomes more pronounced and obligatory synergies become strong. The patient gains voluntary control through the synergy pattern, but may have a limited range within it.
4. Spasticity and the influence of synergy begins to decline and the patient is able to move with less restrictions. The ease of these movements progresses from difficult to easy within this stage.
5. Spasticity continues to decline, and there is a greater ability for the patient to move freely from the synergy pattern. Here the patient is also able to demonstrate isolated joint movements, and more complex movement combinations.
6. Spasticity is no longer apparent, allowing near‐normal to normal movement and coordination.
e.
Measurable & predictable
It is very difficult to apply these words to stroke because:
i.   There is no single industry standard method of measuring stroke deficits, so data on what
works and what doesn’t is hard to do and compare, because there are so many variables.
ii.   Therefore no standard protocol for the best way to recover from hemiplegia & spasticity
has been adequately defined yet.
iii.   There are millions of brain injury survivors like me and the medical community is working
hard to do this.  But, there are a bewildering amount of theories, methods, devices, and
treatments being tried.  Your OT & PT policies make references to some of the studies &
standards, but there are few clear protocols on stroke rehab and skilled & experienced
providers are essential to guide the patient.  I have discussed this issue at length with my
providers and all are frustrated by this.
iv.   Lastly, it takes most of session to make a full evaluation w/ measurements and they prefer
to spend the limited time helping me get to the next level.
v.   They certainly know making predictions is a waste of time.
f.
Timing:
i.   Where am I?  After 2 years, some areas are in stage #3 (foot & hand), other areas are in
Stage #4 (trunk, proximal leg & arm)
ii.   What is typical timeframe?  Providers will not say, but at least another year to get into
stage #5.  No one knows about stage #6
g.
Goal: at least Stage 5
3.
Qualified providers: Again, I am just the patient, but in my opinion, I have a team that is very qualified in neurological rehab.  My rehab providers have been:
a.  http://oregon.providence.org/physician-directory/a/andersen-steven-s/
b. http://www.therapeuticassociates.com/locations/oregon/portlandvancouver/st-helens/h-patrick-corrigan/
c. http://oregon.providence.org/physician-directory/f/fulkerson-deborah-k/
d. http://oregon.providence.org/physician-directory/e/ellingson-marie-c/
e. http://oregon.providence.org/physician-directory/j/joy-jason-c/
4.   In regards to the 4th clause,
a. Physical Condition:
 The following is why I am not the average stroke survivor and expect more
recovery of function than most and will make very good use of additional OT & PT:
i.   While I was extremely unlucky to have had a stroke from Whipples disease, which killed
the sensory-motor control part of the brain:
http://emedicine.medscape.com/article/1166639-overview
 I am fortunate it did not kill me and the brain damage did not affect cognition,
memory, emotions, speech, swallowing, etc.
ii.   Except for the stroke related problems I am actually quite healthy. I know this because
about 60 doctors have treated & examined me. 
They ran every test or scan they could think of to diagnose the Whipples by ruling out
 other causes of infection & stroke (cancer, clots, heart, blood pressure, diabetes, etc.)
iii.   I was a fit, strong, & athletic person all my life, until age 50, when the Whipples infected my
muscles, causing overall soreness & weakness.  On 12/25/12, at age 57, I was 5’-11” &
about 200 lbs., when it infected my upper intestine and caused me to lose 40 lbs. in 4
months, anemia, diarrhea, etc. until I only weighed 161 lbs., then it infected my brain and
caused the stroke on 05/04/13.
iv.   Once diagnosed, IV antibiotics killed the Whipples and all of the systems restored
themselves, except the brain damage.
v.   Fatigue is a big problem for stroke survivors,  and I was no exception.  I slept a lot during
the 1st  year.  Rehab & healing are hard work, plus many of the medications make me drowsy.  Now my energy level is back to normal.
vi.   I am now age 59 and fairly healthy at 190 lbs., working hard to gain strength & function.
vii.   Currently, I spend 2 to 4 hours a day doing my cardio and the exercises recommended by
my therapists.  I do this either at home or  about 2 hours most weekdays at Therapeutics &
Associates in St. Helens at no expense to Lifewise.
viii.   Gratefully, I am likely to live a long time and it is very important for me to recover more
function to live as independent & productive life as possible,
ix.    I am very motivated.
x.   For more details refer to the attached or my medical records:

Plan of Care:
I am not sure what was submitted with request for pre-authorization, but at each session we discuss progress with movement, ADL’s and updates to HEP.  As the patient, the overall rehab plan is as follows:
1)   Medically, I take Baclofen 3 times per day and targeted Botox injections every 3 months.  The Botox does not fix anything, but does reduce the spasticity in the treated muscles for a 2-3 month period, which gives me a window of time for intensive therapy so I can move with intention enough times to build new neuropathways.
2)   PT & OT The attached REHAB HISTORY & PLAN shows frequency of sessions and plan for remainder of policy:
a.   PT: Monthly visits to evaluate changes to gait, posture, function, strength, and adjust HEP to
improve.
b.   OT: Bi-monthly visits to evaluate changes to ROM, function, ADL’s, strength, and adjust HEP to continue improvement.
c.    Depending on scheduling, this is only 6 or 7 more visits  before 11/01/15 when my Medicare begins.
3)   On average I work on HEP 2-4 hours a day x 28 days =84 hours a month.  The visits planned would average 3 hours of paid therapy a month for a 1:28 ratio of paid therapy to what I do on my own.
4)   Rehab is complicated and professional guidance is reasonably needed to maximize my efforts & results
5)   This is not maintenance, since I continue to improve and I will leave to providers to properly document this.
Duplicate Therapy:
I am not sure how to avoid all overlap between PT (leg & foot) & OT (arm & hand), since my level of hemiplegia, spasticity, and lack of feeling is about the same  head to toe on left side only.  Right side is fine.
My last comment regarding these Medical Policies, is how is the patient supposed to know about them, much less fully understand them?  Brings to mind the famous 2010 quote of House Minority Leader Nancy Pelosi (D-CA) about Obama Care: We have to pass the bill so that
you can find out what is in it, away from the fog of the controversy.”
Prior to receiving the denial letters, the following happened:
1.   On 06/08/15, I talked to Lifewise to confirm therapy limit is 30+30 for stroke.  He confirmed, after putting me on hold to check with his supervisor, but said the claim needs neurologic code.  He spot checked 2 prior therapy claims & both had the code.  Also confirmed newer rehab devices or methods need (1) prior approval, (2) proof w/ clinical trials (3) medically necessary, and no list is available of what they will pay.  Did not say the 2nd 30 therapy visits needed prior approval.
a.   On 07/16/15 I called customer service again, and they confirmed again (after putting me on hold to check with his supervisor) and was told currently show 20 rehab visits used to date and I should be able to go over 30, when I get there, but I may need to  call for extension for stroke if they do not do automatically.
2.   I have repeatedly pointed out the language of this benefit on page 5 of the policy to all my providers’ months ago, knowing I would need to exceed the base limit of 30 this year.
3.   My understanding is that my OT & PT have diligently requested prescriptions as needed several times in the 2 years following their “standard procedures” with few problems with Lifewise.
4.   Lifewise has already paid a great deal to date
a.   $ 479k billed in 2013 
b.   $101k billed in 2014
c.    $44k billed to date in 2015
d.   $624k Total billed Whipples stroke related
e.   $343k Total paid  = 55%  of billed on average
5.   By my count in 2015, Lifewise has already issued EOB for 34 visits & has 1 in process.  I am only
requesting 6 more be authorized. The basic approach, frequency, reporting of progress of the previous 85 therapy visits has been fairly consistent & improving for over 2 years, so why is Lifewise changing how my contact is administered now?

I am grateful for all Lifewise has done to insure my care.  Please reconsider the denial quickly, so I can continue my rehab as planned and as the contract allows.
Sincerely,