Appeal type: Medical necessity
Decision: Upheld

Orthopedic
Physical therapy

Diagnosis: Knee injury.
Treatment: Physical therapy.
The insurer denied physical therapy. 
The health plan's determination is upheld. 

This is a male patient who initially began receiving physical therapy for impairments and functional deficits related to knee surgery.

There is a letter of medical necessity from the treating provider stating that the patient underwent knee surgery for anterior cruciate ligament reconstruction using bone patellar tendon autograft. He was placed in a long brace locked in extension for 4 weeks after surgery and required use of crutches. He was enrolled in formal physical therapy to gradually restore his range of motion, strength and ability to perform activities of daily living (ADL) without limitation or pain. It was noted that the patient was seen several times postoperatively and presented with disuse atrophy of the quadriceps muscles with his nerve supply intact. He had limited range of motion due to pain and swelling and was not strong enough to return to activity. He was not ambulating up and down stairs. It was felt the patient needed to undergo formal physical therapy for 5 months to fully resolve these underlying issues.

The Physical Therapy Services in question were not medically necessary for this patient.

The evidence based Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Allow for fading of treatment frequency (from up to 3 visits per week to 1 or less), plus active self-directed home physical therapy (PT) ...Sprains and strains of knee and leg; Cruciate ligament of knee (anterior cruciate ligament (ACL) tear): Post-surgical (ACL repair): 24 visits over 16 weeks."

The records provided indicate the patient underwent knee surgery for anterior cruciate ligament reconstruction. The patient was being treated for the same medical condition, postoperative knee rehabilitation following surgery and had been participating in physical therapy. The patient had an extensive amount of therapy and appeared to progress well. The physical therapy note indicated the patient reporting no pain with walking or running short distances, and feeling better. As of the  progress note, it was stated the patient was feeling much better, with less pain in the front of the knee. He was doing single leg hops, double leg hops up/landing on left lower extremity without support, and walking/running on the treadmill. The patient was able to meet the goal of running one-mile pain-free on a level service at 5 mph(miles per hour). It appears there was still some mild difficulty with descending 20 steps independently pain-free, however, there is no documentation showing that the patient had any significant limitations with essential activities of daily living or any significant ongoing pain or objective deficits. The patient had been instructed in an independent home exercise program and there was no indication as to why this patient would continue to require extensive supervised therapy sessions rather than transitioning to a self-directed independent home exercise program as would be standard of care following the standard 24 visits of postoperative rehabilitation for this condition. There is no evidence to suggest that there be performed in the skilled setting beyond 31 visits was required or that equivalent results could not have been achieved while performing these exercises independently at home.