Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trimalleolar right ankle fracture.
Treatment: Physical Therapy (97110).
The insurer denied the Physical Therapy (97110).
The denial is upheld. 

The records report that the patient is a female with a history that includes lumbar spinal fusion.  She sustained a trimalleolar right ankle fracture.  She underwent surgery.  She started physical therapy.  She was ambulating with a walker, only partially (25%) bearing weight on the right lower limb.  She was working on her right ankle range of motion.  She was to gradually increase her weight bearing until she was bearing full weight on her right ankle.

The patient was standing and ambulating, but with pain.  She was driving for the first time since surgery.  She was reporting nerve pains.  Therapy continued.  She was full weight bearing.  She was no longer using an assistive device to ambulate.  Therapy continued.  The patient's pain persisted.  There was decreased ankle dorsiflexion range of motion.  The patient has had persistently decreased tolerance for activities.  She has reported various sources of stress.  She reports that she is "currently disabled."  She reports that she has been diagnosed with complex regional pain syndrome.  She reports that without physical therapy, there will be adverse effects to her muscles, tendons and ligaments, with tightening and shortening.  She has reported various functional goals that she hopes to reach through more therapy.
   
A letter from the health plan stated that further physical therapy was not to be covered as records establishing that more physical therapy was necessary had not been received.

No, the proposed physical therapy is not medically necessary.
Ankle fractures are typically treated with surgical fixation and/or immobilization.  When mobilization of the injured body part is allowed again, the early part of this convalescence/rehabilitation is often characterized by stiffness, weakness, and functional loss.  Although these symptoms and findings can be slow to improve, there is an absence of high grade evidence that indicates that formal therapy on a prolonged basis confers a marginally significant benefit on outcomes and course over an independent program alone.

Complex regional pain syndrome (CRPS) is a heterogeneous and poorly understood condition that can be provoked by a relatively benign inciting injury.  The treatment of complex regional pain syndrome (CRPS), nonetheless, is challenging, with a dearth of proven, highly effective interventions.

In the current case, there are no specific findings or issues that indicate that ongoing formal physical therapy is necessary for the patient's functional recovery.  She was cleared for weight bearing as tolerated.  She has returned to ambulating without an assistive device and even driving after her right foot fracture and surgery.  She has undergone extensive therapy to date and should be independent with an exercise and palliative modality program.  There is risk of long-term symptomatology or functional impairment on account of her underlying diagnoses, but ongoing physical therapy would not be expected to positively impact her outcomes.  The additional physical therapy in question is not medically necessary based on the available records.

The patient has already undergone extensive physical therapy.  The records do not support the medical necessity of ongoing physical therapy.  More therapy is not expected to marginally improve her outcomes over an independent program.