Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Posterior tibial tendon tear. 
Treatment: Code 97110 - Additional Physical Therapy Services. 
The insurer denied the Code 97110 - Additional Physical Therapy Services. 
The denial is upheld. 

The patient is a female with a history of left knee meniscal repair and bilateral bunion surgeries in the past.  She developed progressive distal right lower extremity pain.  She was found to have a posterior tibial tendon tear.  She was initially managed conservatively, to include immobilization, without resolution.  She underwent a posterior tibial reconstruction with calcaneal osteotomy.  She was given non-weight bearing restrictions for six weeks, followed by a walking cast for six more weeks. 

She was seen for follow-up with orthopedic surgery.  She was walking with a short leg walking cast.  Hardware was noted to be intact on imaging.  She was to transition to a walking boot and start physical therapy. 

She was seen in physical therapy for an initial examination.  She was wearing a right controlled ankle movement (CAM) boot, with instructions to wean out of the boot as tolerated.  She was noted to have decreased right ankle range of motion.  She had an antalgic gait with a shortened stride length.  Right ankle strength measured as follows: 5/5 dorsiflexion, 4-/5 plantar flexion, 4/5 inversion and 5-/5 eversion. 

She was noted to be able to walk further distances without severe pain.  The foot continued to feel stiff.  Right ankle active range of motion measured as follows: 0 degrees dorsiflexion, 45 degrees plantar flexion, 20 degrees inversion and 12 degrees eversion.  Right ankle strength measured as follows: 5/5 dorsiflexion, 4-/5 plantar flexion, 5-/5 inversion and 5/5 eversion.  Therapy continued. 

(Therapy visit #17), she was noted to have been going up and down stairs a lot and cleaning the house. Three days earlier, she had miss-stepped on the stairs and then developed "trouble".  Exercises included various ankle exercises, leg exercises, tandem walking and manual therapy.  Single leg stance (three times 30 seconds) was in place in the home exercise program.  Therapy continued.  She had her "usual discomfort" from her foot arthritis.  There was intermittent discomfort in the feet. 

She had a physical therapy re-evaluation (therapy visit #22).  She was having intermittent symptoms in her feet, which were worse on the left side and worse on days when she was on her feet longer.  Right ankle active range of motion measured as follows: 5 degrees dorsiflexion, 55 degrees plantar flexion, 24 degrees inversion and 12 degrees eversion. 

She was seen for follow-up with orthopedic surgery.  She was noted to still feel weak.  She was unable to do a single leg heel raise.  She was having increased pain after activities with physical therapy had been increased to include eccentric training.  On examination, she was noted to have right ankle inversion weakness without pain.  It was opined that she would benefit from continued physical therapy to increase strengthening of her transferred tendon.  She was to follow-up in six months. 

No, the proposed additional physical therapy services are not medically necessary. 

The patient underwent a right posterior tibial reconstruction with calcaneal osteotomy, which was followed by immobilization of the ankle and non-weight bearing restrictions.  She started therapy.  She had ongoing pain, stiffness and weakness, but she had functional range of motion and strength of the right ankle.  She was able to go up and down the stairs a lot and clean the house.  Therapy visits note that she was largely having chronic pains in her feet attributed to her underlying arthritic condition. 

There are no indications that the patient cannot fully transition to an independent program.  There are no documented exercises that she is doing in the formal therapy setting that she cannot do independently or substitute with independent exercise to further strengthen her ankle and leg.  No marginal difference in clinical course or outcomes would be expected with further formal physical therapy versus a compliantly followed independent program.  The therapy in question is not medically necessary.