Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  s/p ACL and Meniscus surgery.
Treatment:  Physical Therapy - 97110 - Therapeutic procedure, one or more areas, each 15 minutes, therapeutic exercises to develop strength and endurance, range of motion and flexibility; 97140 - Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction) one or more regions, each 15 minutes; and 97535 - Self-care/home management training direct one-on-one contact, each 15 minutes.

The insurer denied the physical therapy - 97110 - Therapeutic procedure, one or more areas, each 15 minutes, therapeutic exercises to develop strength and endurance, range of motion and flexibility; 97140 - Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction) one or more regions, each 15 minutes; and 97535 - Self-care/home management training direct one-on-one contact, each 15 minutes.  The denial is overturned. 

The patient is a female with history of left ACL (anterior cruciate ligament) and Meniscus surgery performed by the qualified orthopedic surgeon.  Prior to the trauma, the child has been very active in sports.  The child has been prescribed postoperative physical therapy (PT) interventions, and she received 32 visits provided by the qualified physical therapist. 

Clinical records demonstrated limitations in ROM (range of motion) of the patient's left knee with decreased strength, leading to additional physical therapy interventions approved by the health plan.

The telemedicine visit points out on improvement in both pain and overall wellbeing.  The therapist recommended ongoing PT interventions for strength and conditioning.  Physical therapy in-person visits have been disrupted due to COVID-19.  In-person examination by the physical therapist points out "significant atrophy of the left leg," and tenderness on palpation over the patella with normal range of motion and no evidence of knee instability. 

Additional PT interventions have been recommended for two months, with gradual return to sports activities.  The Health plan denied supervised physical therapy treatment, specifically:  97110 - Therapeutic procedure, one or more areas, each 15 minutes, therapeutic exercises to develop strength and endurance, range of motion and flexibility; 97140 - manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction) one or more regions, each 15 minutes; and 97535 - Self-care/home management training direct one-on-one contact, each 15 minutes, due to lack of medical necessity based on the review of pertinent clinical data and health care policy provisions.

The parent of the child appealed the health plan's determination.  Letter of medical necessity has been furnished by the operating surgeon in support of additional outpatient therapy interventions.

Yes, the 97110 - Therapeutic procedure, one or more areas, each 15 minutes, therapeutic exercises to develop strength and endurance, range of motion and flexibility, 97140 - Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction) one or more regions, each 15 minutes, and 97535 - Self-care/home management training direct one-on-one contact, each 15 minutes are medically necessary.

In this case, the child's home exercise program has not been provided under the guidance of skilled physical therapist.  There are extenuating circumstances, more specifically, onset of COVID-19 pandemic, which led to relative immobility of the left lower extremity and subsequent  development of atrophy and weakness reported by the most recent in-person visit to the well-qualified orthopedic surgeon, who continues to recommend outpatient physical therapy for the next two months. 

In a case such as this, eight sessions of skilled physical therapy provided over two months, with emphasis of home exercise program and return to sports activities, would be considered as congruent with the standards of care.