Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Physical Therapy. 
The insurer denied Physical Therapy. 
The denial is upheld. 

This is a female patient diagnosed with neck pain. The letter of denial from the insurer states physical therapy was denied as they need to see notes showing that the patient still has pain and is not able to do all daily tasks without significant impairment. The notes were reviewed and show the patient still had some pain in the neck with certain movement and having reduced motion in some directions, but the notes show that the patient is able to do all daily tasks without significant impairment and does not meet criteria for additional physical therapy.
The patient reports she is in pain daily and this limits functioning. The patient does not understand why she cannot have physical therapy until her pain is fully healed. The patient reports that she cannot carry her daughter's backpack.
It was noted the patient had an exacerbation of her neck and shoulder pain one week prior when she put pressure through her left arm and felt shooting pain in the neck and shoulder. Afterwards she was able to use her arm for a few days and had a lot of difficulty turning her head to cross the street. Since then, she improved somewhat and was able to easily turn to the right. Turning to the left was still painful and she had difficulty looking up to see things on high shelves. She reported she still cannot walk with packages. It was noted she still has stamina limitations but has improved cervical rotation range of motion. Her pain is rated currently at 3/10. There was minimal improvement in disability index score since last visit from 18 to 16. There was near full range of motion to the cervical spine although there was hesitancy and pain with side bending on the right, unchanged since prior visit. Motor strength was unchanged since prior visit. Additional physical therapy was recommended by her provider.
At issue is the medical necessity of Physical Therapy.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Physical Therapy is not medically necessary for this patient.
Additional physical therapy (PT) is not medically necessary. The patient is unlikely to have any significant measurable improvement in a reasonable amount of time and there are no significant deficits with essential activities of daily living. While the patient is noted to have some pain complaints, range of motion is nearly full and there has been no change in motor strength since the prior reevaluation. There is no need for ongoing skilled intervention as the patient would be expected to transition to an independent home exercise program to continue progressing independently. Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Allow for fading of treatment frequency (from up to 3 visits per week to 1 or less), plus active self-directed home PT. Cervicalgia (neck pain); Cervical spondylosis: 9 visits over 8 weeks." Standard of care would be transitioned to a fully independent home exercise program as there are minimal deficits remaining on exam, the patient has completed the standard recommended number of sessions for this condition and would be expected to have been provided with a home exercise program.
Therefore, the requested health service/treatment of Physical Therapy is not medically necessary.