Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Patellar Tendon Rupture Revision Repair

Treatment: Physical Therapy Services

The insurer denied the physical therapy services. 

The denial was upheld.  

This is a male patient who has been participating in physical therapy services after a fall on an escalator.  The patient participated in physical therapy services and was working to improve his strength and range of motion.  According to the notes the patient has been making improvements with physical therapy. However, he continues to have limited range of motion and limited strength of the left lower extremity.  Due to the decreased strength he was having difficulty performing activities of daily living.  The recommendation was made for additional physical therapy visits.  A physical therapy note indicated the patient has participated in 29 visits with 7 cancellations.  The objective examination indicated there were no new complaints.  The patient had 5/5 strength with hip abduction with -5/5 and hip extension as well as ankle dorsiflexion and plantarflexion.  There was also 5/5 strength with hip flexion, knee extension, and knee flexion.  The documentation indicated the patient presented with improvement in the TUG time with noted increases in gait speed since prior assessment.  Although increases have been noted they are slight, and the patient continued to present with significant functional deficits.  It was recommended he continue with therapy services.

Per medical literature, physical therapy is recommended for patients who have pain and decreased functional deficits as a result of injury or illness in order to achieve increased range of motion and strength.  Additionally, physical therapy is supported when it is expected to result in significant therapeutic improvement over a clearly defined period of time, there is documentation outlining quantifiable and obtainable treatment goals, and during the therapy process there must be documented objective evidence of improvement.  Physical therapy focused upon improving the strength of the knee, hip, and core muscles, including the hip abductors and quadriceps, are generally effective as a sole treatment for patellofemoral pain.

In this case it is noted the patient underwent surgical intervention.  The documentation indicated this patient has participated in 29 visits with 7 cancellations.  The physical examination did not reveal any significant abnormalities.  There was slightly decreased strength and -5/5 with an increase in gait speed since the prior therapy assessment.  The notes did indicate although increases have been noted they are slight, and the patient continued to have significant functional deficits.  While post-operative physical therapy is typically recommended by peer-reviewed literature, the submitted documentation does not indicate why this patient would need to continue therapy services seven months beyond surgical intervention.  The note provided does not detail any significant deficits and given it has been seven months since surgical intervention the patient should be well versed in a home exercise program and therefore additional therapy is not needed.  

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for physical therapy- 97110 (60 units) for future dates of service is upheld.  The medical necessity is not substantiated.