Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a 68-year-old female who underwent a right total hip replacement on 1/08/18.  She underwent physical therapy postoperatively.  She had hip pain, as well as low back pain. As of 3/13/18, she was doing yoga and walking one to two miles daily.  She had active right hip flexion to 112 degrees and active right hip abduction to 40 degrees. Strength was fair to fair minus in the hips bilaterally. Strength at the hips was symmetric. Strength at the knees was intact bilaterally. As of 4/26/18, she was noted to have 3/5 hip abduction strength. On 5/01/18, she was noted to have ridden her bike for 15 to 20 minutes over the prior weekend, without problems. Therapies continued, which included soft tissue massage, stretching and therapeutic exercises. The patient has requested reimbursement for CPT codes 97530-59, 97110 and 97140 provided on 5/03/18, 5/08/18 and 5/10/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The literature related to optimal rehabilitation and exercise following total hip arthroplasty have been reported to be limited with respect to trial and data quality. Di Monaco and Castiglioni reported that favorable outcomes in the early postoperative phase were due to ergometer cycling and maximal strength training, while late (greater than eight weeks postoperative) phase advantages were due to weight-bearing exercises.  Their conclusion was that there was insufficient evidence to design an evidence-based exercise protocol after total hip replacement, with sparse data to support specific exercises to add beyond the usual mobility-related training. Lowe and colleagues concluded in a review that, physiotherapy exercise after discharge following total hip replacement may potentially benefit patients in terms of function, walking and muscle strengthening, but the evidence was insufficient to determine that physiotherapy after hospital discharge was indeed an effective intervention. The overall quantity, quality and diversity of the available literature precluded meta-analyses. Walsh and colleagues noted that there was strong evidence to support exercise to improve pain, function and quality of life in the setting of lower limb osteoarthritis, but limited evidence to support the use of commonly utilized physiotherapy interventions. Per the authors, studies that investigate packages of care required further investigation.  In this case, the patient underwent a right total hip replacement on 1/08/18. As of March 2018, she was doing yoga and walking one to two miles daily.  As of April 2018, she was able to ride a bicycle for 15 to 20 minutes without problems. Although she continued to have symptoms, range of motion deficits and strength deficits in her lower limbs, there were no indications that she could not have continued an exercise program on her own in order to improve her function. There was no need for ongoing formal exercise and manual therapy.  The physical therapy services in question were not medically necessary per the available clinical documentation and the medical literature. Thus, CPT codes 97530-59, 97110 and 97140 provided on 5/03/18, 5/08/18 and 5/10/18 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.