Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 16-year-old female who has a history of a left knee anterior cruciate ligament reconstruction with a quadriceps tendon autograft in September 2018. The patientas parent has requested authorization and coverage for physical therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the literature related to rehabilitation after anterior cruciate ligament (ACL) reconstruction supports early weight bearing, early range of motion exercise, and closed kinetic chain activities. The early rehabilitation process should be monitored closely to protect against graft failure and other complications. As strength improves, open kinetic chain activities and more functionally advanced work can be introduced, although demanding physical activity is generally avoided during the first three postoperative months. Rehabilitation following ACL reconstruction, overall, can require a prolonged period of time. The entire rehabilitation process following ACL reconstruction, however, does not requires a formal therapy setting. Home-based programs have been shown to result in similar long-term outcomes to more clinically supervised programs, particularly for the recreational sports participant. The rehabilitation process can be more complicated, however, particularly for return to activities placing significant stress on the knee. Regaining higher level neuromuscular control of core muscles and optimizing other biomechanics factors are important to improve functional outcomes and mitigate risk of re-injury of the repaired ACL, as well as contralateral knee injury. Assessment and treatment of the injured knee, as well as the addressing of potentially disadvantageous compensatory biomechanics is appropriate for a comprehensive rehabilitation program following ACL repair. Ultimately, each rehabilitation program needs to be reviewed on an individual basis, depending on the specific functional needs in each case. Therapy protocols after meniscal repair typically call for avoiding weight bearing and excessive range of motion in the early postoperative period. There is, however, no clear evidence-based consensus on optimal protocols, as accelerated and more aggressive programs have also been shown to have benefit, particularly when meniscal repairs are performed in association with an ACL reconstruction. In any case, a period of supervised formal therapy following meniscal repair is warranted to initiate the program, followed by a transition to self-directed exercises when possible and appropriate. In the current case, the patient underwent a right knee ACL reconstruction with quadriceps autograft, as well as medial and lateral meniscus repairs in early March 2020. Postoperatively, she had a slow recovery of her range of motion but ultimately gained full extension and functional flexion. She had complaints with various activities such as walking on uneven surfaces, but there are no indications that she has any limitations with her mobility-related activities of daily living at that time. Although the patient has not fully recovered from her right knee surgery, the medical necessity of the requested additional 24 therapy visits is not established. There are no exercises that she is performing in the formal therapy setting that could not be performed independently or substituted with independent exercise. There are no indications that she is unable to do an appropriate home exercise program. At this stage many months postoperatively, and with full knee extension already established long ago, there is no benefit of ongoing formal manual therapy over stretching and use of self-applied modalities (e.g., foam rollers) that can be performed independently. She will have a guarded prognosis with respect to future injuries if she continues to participate in activities and sports such as soccer, but the additionally proposed therapy in question is not expected to marginally improve her risk profile. Therefore, the requested physical therapy is not medically necessary for the treatment of this patient.