Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Physical Therapy. 

The insurer denied Physical Therapy Services for medical necessity. 
The denial was upheld. 

This is a male patient that initially began receiving physical therapy service from a nonparticipating provider for impairments and functional deficits related to a knee surgery (anterior cruciate ligament (ACL) reconstruction). The patient had previously been participating in physical therapy for functional deficits related to the knee surgery. Documentation submitted indicated the patient had reached maximum therapeutic benefit with the care plan. It was noted the patient had completed 36 visits over several months. 
The progress note demonstrated very good clinical status with range of motion 0-125 and strength was "good to good plus." 
There is a letter of medical necessity from the provider stating that the patient underwent left knee surgery. The patient was placed in a long brace locked an extension for 4 weeks after surgery and required the use of crutches. He was enrolled in formal physical therapy to gradually restore his range of motion, strength, and ability to perform activities of daily living (ADL)s without limitation or pain. It was noted the patient was seen several times postoperatively and presented with disuse atrophy of the quadriceps muscles with his nerve supply intact. He had limited range of motion due to pain and swelling and was not strong enough to return to activity. It was felt the patient needed to undergo formal physical therapy for months to fully resolve these underlying issues and that it was the provider's standard protocol for all ACL reconstruction patients without any other type of setbacks after surgery to undergo a minimum of 6 months of formal physical therapy in order to make a full recovery. 

The health plan's determination of medical necessity is upheld in whole. 
The requested health service/treatment of Physical Therapy Services was not medically necessary for this patient. 
Records provided indicate the patient underwent left knee surgery for right knee anterior cruciate ligament reconstruction. The patient was being treated for the same medical condition, postoperative knee rehabilitation following surgery and had been participating in physical therapy. The patient had 36 therapy sessions and appeared to progress well. 
A progress note demonstrated very good clinical status with range of motion 0-125 and strength was "good to good plus." The patient was actively performing exercises on the treadmill at 10 mph(miles per hour) and doing multiple exercises such as single leg hops, and squats holding for 10 seconds. The patient had been instructed in an independent home exercise program and there was no indication that this patient would continue to require supervised therapy sessions rather than transitioning to a self-directed independent home exercise program as is the standard of care following the standard 24 visits of postoperative rehabilitation for this condition. There is no documentation to suggest that therapy performed in the skilled setting was required or that equivalent results could not be achieved while performing these exercises independently at home, which is the generally accepted standard of care. 

Therefore, the Physical Therapy Services are not medically necessary.