Appeal type: Medical necessity
Decision: Upheld

This is a patient who began receiving physical therapy for neck pain. Records indicate that a prospective request for physical therapy services was approved for coverage up to a maximum of 3 times modality codes. It is noted that a request for an additional fourth timed unit was denied for the service dates in question as there was a lack of need for skilled intervention described in the clinical documentation. 
The health plan's determination is upheld. Records indicate that the dates in question represented physical therapy visits #9 and #10 for the same condition and it was noted that the active care plan was repetitive (e.g. upper body ergometer (UBE) x 5 minutes, seated rows, triceps Brachii (TB)-side lying horizontal abduction and external rotation (ER), wall angles, etc.) and was not considered skilled requiring a licensed professional such as a physical therapist to perform these exercises. There was also little support for the continuous application concerning the rationale for manual care (97140) given the stage of care and the documentation did not provide a detailed rationale such as high pain scores, joint hypermobility, or range of motion deficits. The patient reported her neck had generally felt better since the last session. The provider billed 45 minutes (3 timed codes) for therapeutic exercise (chin tax, cervical isometrics, seated rows, there a band horizontal abduction, there are band external rotation, wall angles, prone shoulder extension, prone T's). The provider also billed 15 minutes of manual therapy with single-level thoracic manipulation (STM)/suboccipital release for the neck. There was no physical exam performed or pain levels documented. The provider billed 45 minutes (3 timed codes) for therapeutic exercise (chin tax, cervical isometrics, seated rows, there a band horizontal abduction, there are band external rotation, wall angles, prone shoulder extension, prone T's). The provider also billed 15 minutes of manual therapy with STM/suboccipital release for the neck. This was noted to be visit #10 and it was noted that in general the patient reported she had been able to maintain her neck improvement although did have 1-2 worse unusual days the prior week without any clear reason. There was no physical exam performed or pain levels documented. As of the dates of service in question, there is no clear indication as to why the patient would require passive manual therapy. There was no indication of a significant flare up of symptoms, no pain levels documented and no exam findings suggesting a severity of symptoms that would require passive modalities over that of active therapies. There was no indication of significant myofascial pain or muscle tension. There was no discussion of clinical decision-making or detailed analysis of patient progress or explanation regarding rationale for choosing this particular intervention. There is no clear indication as to why the patient would require passive manual therapy. There was no indication of significant flare up of symptoms, no pain levels documented and no exam findings suggesting a severity of symptoms that would require passive modalities over that of active therapies.