Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back and leg pain
Treatment: Physical Therapy Services
The insurer denied: Physical Therapy Services
The denial is upheld.

The patient is an adult male with a medical history of low back and leg pain. Physical therapy documentation indicated that the patient was doing better overall. The patient was noted to have ongoing lumbar spine pain that radiated into the right lower extremity. He was noted to have pain that was 6/10 in intensity that was worse with activity and sitting. Range of motion of the lumbar spine was noted to be 36 degrees with forward bending, 32 degrees with backward bending, 26 degrees with rotation, and 32 degrees with side-bending. Motor strength was noted to be fair to poor and 3/5. The patient received electrical stimulation,
cupping and a hot pack. He performed stretching and strengthening exercises. The patient had received 34 sessions of physical therapy. The patient was initially evaluated. The patient had had 29 sessions of physical therapy. The patient received electrical stimulation, cupping and a hot pack. He performed stretching and strengthening exercises. The patient had had 11 sessions of physical therapy. The patient received electrical stimulation, cupping and a hot pack. He performed stretching and
strengthening exercises. He was noted to have tenderness to palpation of the thoracic and lumbar spine. The physical therapy was considered not medically necessary per guideline policy with the rationale there was a lack of meaningful response to physical therapy and documentation supporting the effectiveness of ongoing skilled physical therapy. It was considered maintenance in nature. This decision is being appealed.

The physical therapy was not medically necessary.

The patient is an adult male with a medical history of low back and leg pain. Physical therapy documentation indicated that the patient was doing better overall. The patient was noted to have ongoing lumbar spine pain that radiated into the right lower extremity. He was noted to have pain that was 6/10 in intensity that was worse with activity and sitting. Range of motion of the lumbar spine was noted to be 36 degrees with forward bending, 32 degrees with backward bending, 26 degrees with rotation, and 32 degrees with side-bending. Motor strength was noted to be fair to poor and 3/5. The patient received electrical stimulation,
cupping and a hot pack. He performed stretching and strengthening exercises. The patient had received 34 sessions of physical therapy. He was noted to have tenderness to palpation of the thoracic and lumbar spine. The patient has a medical history of lumbar spine pain and sciatica. The patient continued to receive physical therapy for dates of service. This primarily entailed electrical stimulation, cupping and therapeutic exercise, which included stretching and strengthening exercises. While the medical literature supports the use of physical therapy in
patients with lumbar spine pain, there is no clear consensus in terms of the amount and frequency of therapy provided, especially when routine exercises can be accomplished in the context of a home exercise program. This patient was receiving ongoing electrical stimulation and cupping, which has not been shown to significantly help patients with low back pain. The patient did not have significantly impaired function or mobility and the exercises being performed did not require the oversight of a skilled physical therapist.