Obtaining Appropriate Treatment
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Case Challenge #3
A patient, whose rotator cup was operated on twice, reached the end of her 24 approved physical therapy visits. A prior MRI had shown full thickness tear. However, her current physician's report indicated adhesive capsillitis, and her doctor and physical therapist wanted to avoid a lapse in therapy to prevent "frozen shoulder".

Our Solution
When approval for more physical therapy was requested of the claims examiner, he directed our nurse case manager to their utilization review, which required current physical therapy reports and current prescriptions. The Nurse quickly and efficiently obtained these documents, along with a current PR2 and an interim report from physical therapy that emphasized the patient's need for immediate approval. Authorization was given for the requested physical therapy within 6 days. The patient went so far as to personally thank the nurse, without whom the approval never could have been received so quickly.