Preoperative insurance-mandated physical therapy does not prevent the need for shoulder arthroplasty in patients with glenohumeral osteoarthritis

Abstract

Background

Glenohumeral osteoarthritis (GHOA) is a common cause of shoulder pathology for many patients. Nonsurgical treatment options for advanced GHOA are limited, and there are currently no high-level studies supporting the use of physical therapy (PT) to treat advanced cases of GHOA. Despite this, there has been an increasing requirement for insurance-mandated PT before shoulder arthroplasty. The purpose of this study was to investigate patients with shoulder arthritis who were denied shoulder arthroplasty by their insurance carriers based on the lack of preoperative PT. We further sought to assess health-care provider's perception regarding frequency, duration, and overall impact of the peer-to-peer (P2P) process.

Methods

This was a multicenter case series of patients with moderate to severe GHOA who were denied shoulder arthroplasty by their insurance carrier due to lack of preoperative PT. The cohort was followed to assess if a P2P took place and if patients were required to perform formal preoperative PT before shoulder arthroplasty. Variables collected included demographic data, insurance carrier status, preoperative range of motion, preoperative patient-reported outcome measures (PROMs), and postphysical therapy PROMs. A survey was administered to assess health-care provider's perception of the frequency, duration, and overall impact of the P2P process.

Results

A total of 12 patients were included for analysis. Eleven patients (92%) ultimately underwent the indicated shoulder arthroplasty, and 1 patient was undergoing mandated PT at the time of analysis. Ten of the 12 cases (75%) underwent a P2P. Six P2P appeals (60%) were unsuccessful, and 5 of those patients were required to undergo a course of preoperative PT. Two cases did not undergo a P2P process but were still required to perform PT. A total of 7 patients (58%) were required to undergo formal preoperative PT and 6 of those 7 patients (86%) ultimately underwent shoulder arthroplasty. Results from the survey show that almost half of health-care respondents spend between 40 and 60 minutes on P2P appeals.

Conclusion

Despite the lack of evidence to support PT for the treatment of GHOA, many patients indicated for shoulder arthroplasty are denied the surgery by their insurance due to lack of preoperative PT. Insurance-mandated preoperative PT in this cohort did not significantly improve range of motion, pain, or prevent the need for shoulder arthroplasty. Results of this study highlight a significant burden to providers and to patients who are denied a shoulder arthroplasty in the setting of moderate to advanced GHOA.