Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unspecified fracture of the head of the right femur
Treatment: Physical therapy
The insurer denied Physical therapy.
The denial is overturned.

The records indicate that the patient is an adult female with a history of a motorcycle accident resulting in a displaced, supracondylar distal right femur fracture with intercondylar extension. She underwent open reduction internal fixation surgery. She was discharged from the hospital on post-operative day (number) #3. She remained in a knee immobilizer for two weeks, then there were non-weight bearing restrictions. As of approximately six weeks out, she was allowed toe-touch weightbearing restrictions, which was to progress to weightbearing as tolerated in two weeks. She received home therapy with passive range of motion. Two weeks later, the patient started outpatient physical therapy. Therapy included exercises, manual therapy, and electrical stimulation. Three weeks later, the patient had 0-68 degrees of right knee active range of motion. Right hip strength was 4/5. Right knee strength was 3/5. There was right quadriceps femoris weakness. She had poor single leg balance on the right leg. Gait was antalgic. As of the following week, the patient had undergone 15 therapy visits. She continued to have weakness and stiffness affecting the right leg. She was ambulating with an axillary crutch. She had difficulty with activities of daily living. Additional therapy beyond 15 visits was not approved for coverage by the health plan. Additional physical therapy was prescribed, 2-3 times a week for 8-12 weeks. After nearly 3 weeks later, the patient reported that she ambulates with a cane. She is bending her right knee to only 72 degrees. She is having difficulty donning her sock and shoe on the right side. She reported inability to work. She was paying for physical therapy out of pocket.

The requested physical therapy is medically necessary.

As of 15 outpatient therapy visits, the patient was still early in her recovery course after a high energy fracture involving the distal right femur, which extended into the intercondylar area and required extensive operative repair. She was making progress from a bilateral crutch gait with non-weight-bearing to toe touch weight-bearing on the affected limb to an initial bipedal gait with weight-bearing as tolerated on the affected limb. She continued to have severe limitations in strength and range of motion at the affected knee, translating into very basic functional deficits, such as inability to perform basic clothing tasks. She continued to require skilled therapy services to address her severe weakness (only at about antigravity level) and especially her range of motion deficits (with substantially less than 90 degrees of knee flexion). Ongoing skilled therapies after the 15 covered therapy visits was and is appropriate to address the patient's functional needs, with an aim of working towards restoring as much function and independence as possible given her premorbid functional baseline, and to mitigate the risk of complications such as, but not limited to, a knee contracture potentially requiring further operative intervention.