Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee pain.
Treatment: Additional Physical Therapy (code 97110).
The insurer denied the Additional Physical Therapy (code 97110).
The denial is upheld.

The records indicate that the patient is a female with a history of chronic intermittent right knee pain.  She had a history of a right medial patellofemoral ligament reconstruction several years prior.

The patient presented to a physical therapy practice with an episode of recurrent right knee pain that had started approximately two months earlier.  There was increased pain with exercise, walking on hills, and hiking.  Her symptoms were better with rest, ice, and ibuprofen.  On assessment, she had reduced right hip strength, severely decreased right iliotibial band tightness, reduced right ankle passive range of motion, reduced right ankle strength, and inability to perform a single leg squat.

The patient started a program of therapy that included therapeutic exercises, therapeutic activities, and manual therapy.  She concomitantly performed a home exercise program.  She was noted to have persistent intermittent pains at the right knee.  She was frustrated.  Over the ensuing weeks, her pain improved.  She still felt weak.

The patient had undergone several therapy visits.  Right knee active range of motion was noted to be unremarkable.  There were mild improvements in her right lower limb strength.

The health plan declined to cover the additional physical therapy in question, noting that the documentation did not establish that all plan criteria for coverage were met, including making progress towards goals in a reasonable amount of time, and a need for a skilled therapy provider.  The patient noted that she had been referred for therapy.

No, the Additional Physical Therapy (code 97110) is not medically necessary.
The medial patellofemoral ligament (MPFL) is the main stabilizer of the knee that resists lateral subluxation/dislocation.  It can be compromised during a lateral patellar dislocation event.  Conservative management alone, unfortunately, is often unsuccessful in preventing recurrent instability.  MPFL (medial patellofemoral ligament) reconstruction, in conjunction with other stabilizing surgical interventions when warranted, is often employed to mitigate the risk of recurrent patellar instability.

Rehabilitation protocols after MPFL (medial patellofemoral ligament) reconstruction and patellar stabilizing surgery generally include periods of reduced weight bearing and knee immobilization immediately postoperatively, aimed at protecting the graft.  Passive range of motion is then employed to mitigate risk of arthrofibrosis.  Typically, full range of motion and full weight bearing are gradually reintroduced, while rotational maneuvers involving the knee are often avoided initially.  Once full range of motion at the knee, adequate single leg bent-knee strength, good dynamic neuromuscular control during functional activities, and lack of patellar apprehension are achieved, patients can begin their return to sports activities.

A standard, validated rehabilitation protocol after patellar stabilizing surgery, nevertheless, does not exist.  Best practices related to the duration and extent of immobilization and weight bearing restrictions are poorly defined.  Criteria and protocols for advancing the therapy program are also unclear.  Outcomes data related to various publicly available protocols, notably, remain scarce and there is also emerging evidence that unsupervised home regimens may be as effective as supervised rehabilitation.

In the present case, the patient had undergone MPFL (medial patellofemoral ligament) reconstruction several years prior.  While she had ongoing intermittent right knee symptomatology, there were no expectations that formal therapy would have favorably impacted her clinical course or outcomes beyond an independent program based on the clinical records and medical literature as discussed above.  There were no impairments that would have precluded an independent exercise and modality program.  There was no need for passive modalities provided in the formal setting.  Manual therapy has no proven role in this clinical setting.

Yes, The health plan appropriately denied coverage of the requested service given that there was no need for a skilled therapy provider in this clinical scenario of chronic intermittent knee symptoms years after a patellar stabilizing surgery.  The services were not necessary.