Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right little finger nondisplaced distal phalanx fracture.
Treatment: Occupational Therapy (97530).

The insurer denied the Occupational Therapy (97530).  The denial is overturned. 

The patient sustained trauma to her right little finger resulting in a nondisplaced distal phalanx fracture extending into the joint.  The fracture was treated with a splint, then she eventually returned to regular activity.  She was doing some gardening/yard work when she felt a pop in the finger.  She was diagnosed with a re-fracture of the distal phalanx with displacement.

The patient underwent closed reduction and percutaneous pinning. She was then seen in follow up.  The pin was pulled.  She was neurovascularly intact.  She was fitted in a splint.  The patient was again seen in follow up.  She had no pain.  She was to start occupational therapy for range of motion work.  

The patient has reported that she feels stiffness in her entire right hand.  She feels a strain in the hand when she lifts anything light or heavy.  She is a professional musician and teacher.

Yes, the proposed occupational therapy (OT) is medically necessary.

Fractures of the fingers with intra-articular involvement are injuries that can have severe ramifications in hand function due to the development of post-traumatic joint stiffness (Packham TL, et al.).  This stiffness and range of motion loss, even at the distal interphalangeal (DIP) joint, can be particularly functionally impairing for persons who depend on fine hand motor function of all of their fingers for occupational or vocational purposes, e.g., surgeons, athletes and musicians.

Articular fractures of the distal interphalangeal (DIP) joint can be managed either nonoperatively or surgically, with no clear consensus on absolute indications for surgery, or ideal surgical intervention (Chen F and Kalainov DM).  In either treatment scenario, physical/occupational therapy can play a significant role in mitigating risk of development of post-traumatic finger stiffness, optimizing functional outcomes, patient satisfaction, and return to activity (Shaftel ND and Capo JT,; Lutsky KF, et al.).  In cases of persistently symptomatic and irreparable DIP joint injury, fusion of the DIP joint may be indicated (Chen F and Kalainov DM).

The patient in this case sustained a distal interphalangeal fracture of her little finger.  There was intra-articular involvement.  She was first managed conservatively with immobilization.  Afterwards, she was cleared to resume regular activities; however, she developed a refracture which required surgical intervention.  She underwent pin fixation, subsequently removed, as well as further  immobilization.  She has had functional symptomatology involving the whole hand, with diminished lifting ability.

An occupational therapy/hand therapy evaluation and initiation of therapy services to formally assess range of motion and function, optimize function, and provide education for a home program would be appropriate following her hand surgery and prolonged immobilization periods with persistent functional complaints.  This would be consistent with the evidence-based medical literature and current clinical practice.

The patient had a complicated course where conservative management failed to resolve her condition and she developed a refracture without significant new trauma.  She underwent surgery for the finger re-fracture, which was now displaced, and already included intra-articular involvement.  Given this complicated injury scenario and course, she was at even greater risk for suboptimal outcomes, already elevated due to the intra-articular involvement.  Hand therapy evaluation and treatment would be standard and appropriate clinical treatment for her condition, and supported by the medical literature.  This therapy need not be prolonged.