Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fractured tibia. 
Treatment: Physical therapy. 
The insurer denied coverage for physical therapy. 
The denial is overturned. 
 
This is a female who suffered a comminuted spiral fracture of the tibia and tibial plateau and was externally fixated for two weeks, then underwent open reduction internal fixation (ORIF) with 17 plates and screws with three months of non-weight-bearing. The patient has received physical therapy to address abnormalities of gait and mobility. The service in question is physical therapy which is under review. 

The health plan states that there are no objective and measurable findings noted. It also states that the undated evaluation details her initial status. It claims there is no formal reassessment submitted for review and none of the submitted therapy notes include broadly accepted measurements of treatment outcomes, objective measurable clinical findings, or functional outcome measures. As such, the efficacy of ongoing care is not supported by the documentation submitted. Coverage was denied as not medically necessary. 

However, there are objective measurements submitted and functional progress listed per the progress note. This includes functional measures, such as Five Times Sit to Stand, gait speed, as well as lower extremity strength and ability to perform other functional tasks, such as ambulating one mile and performing social activities. 

Per McLaughlin, K. H., et al, (2021), "Evidence suggests that physical therapy improves clinical outcomes such as range of motion, gait speed, and function." Per Iliopoulos, E., & Galanis, N. (2020), "Other evidence states that physical therapy is a very important part of the patients' rehabilitation during their journey to return to their pre-injury activity levels or as close as they can to that state." 

In this case, the patient has shown functional progress as documented in the progress note. Specifically, the patient had shown gains in Five Times Sit To Stand, gait speed, lower extremity strength, and improvement in functional tasks. The patient had also shown gains in the Lower Extremity Functional Scale. Therefore, the request is appropriate and approved. 

Per Thompson, J. H., Koutsogiannis , P., & Jahangir, A. (2022), "The management of tibial fractures requires an interprofessional team that includes an orthopedic surgeon, emergency department physician, radiologist, nurse, and a physical therapist. These fractures have very high morbidity and the nurse monitoring the patient should be aware of the risks of deep vein thrombosis and compartment syndrome. The leg has to be monitored for pulse, color, temperature and neuropathic changes to ensure that compartment syndrome is not developing. Even after treatment, most patients need a prolonged recovery period combined with physical therapy." 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for continued physical therapy (PT), 97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility; 97112x2 Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities; 97140 Manual Therapy techniques one or more regions, each 15 minutes; and 97530 Therapeutic activities, Direct (one-on-one) patient contact, each 15 minutes is substantiated.