Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior Cruciate Ligament Tear

Treatment: Physical Therapy Services

The insurer denied coverage for physical therapy services

The denial is upheld

This case involves a male who has a history of right knee pain with stiffness and swelling as a result of prior surgical intervention.  The documentation indicated that the patient underwent an anterior cruciate ligament reconstruction with bone patellar tendon autograft and a medial meniscus and lateral meniscus repair.  The documentation indicates this patient has participated in postoperative therapy services.  The documentation indicated this patient was seen for a therapy visit.  The documentation indicated the patient continued to progress with core stability as well as range of motion, strength, flexibility and balance.  It was noted that the patient was ambulating without an antalgic gait and had no pain.  The documentation detailed patient was recommended to continue treatment.  According to the provided documentation, this was visit 6/10 approved visits.  He did indicate at this visit he had been working out more at the gym and there were no difficulties noted with therapy participation.  He continued to be seen for further therapy.  It was noted that he was presenting with increased right lower extremity strength as well as endurance and flexibility.  He was being seen for visit #11.  He stated he continued to workout regularly and focus on right lower extremity strength.  An addendum in the medical record indicated the patient initially presented with right lower extremity atrophy.  He was not independently jogging or performing light agility activities due to the need for supervision for the correct technique.  The patient at that time was not allowed to return to sports.  It was recommended he continue with additional therapy treatment.

This patient has a history of right anterior cruciate ligament tear while playing lacrosse. He reported that immediately he was able to weight bear, but the morning after weight bearing was limited due to pain and stiffness. A few weeks later, underwent anterior cruciate ligament reconstruction with bone patellar tendon autograft and a medial meniscus and lateral meniscus repair. He continued to have difficulty with mobility and activities of daily living.  With therapy, the patient progressed to demonstrate almost full right lower extremity, range of motion, quad control, and had progressed to jogging, without pain. He had continued limitations with hopping. He was noted to have positive Trendelenburg gait. Based on the current medical literature, physical therapy for mobilization is recommended after anterior cruciate ligament reconstruction to assist in regaining function and symptom management. However, he has had functional improvement and further therapy beyond the approved dates does not indicate expected resolution or improvement beyond the already achieved improvement in the patient's function. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the physical therapy services provided is upheld. Medical necessity is not substantiated.