Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ACL (Anterior Cruciate Ligament) Injury. 
Treatment: Physical Therapy Services. 

The insurer denied coverage for physical therapy services. 

The denial is upheld. 

The patient is a female with a history of severe knee injury as a result of soccer injury. The patient underwent a right knee anterior cruciate ligament reconstruction, medial collateral ligament repair and iliotibial band tenodesis. Patient was hospitalized for three days. She still had symptoms and pain with daily activities despite showing progress. He encouraged the patient to work with her physical therapist on specific goals. Physical therapy is necessary for the patient to meet the qualitative movement assessment (QMA) benchmarks prior to being cleared to participate in physical education and youth sports. She could run an extensive risk of re-injury and potential surgery. Resuming complete activity before meeting the criterion could cause her further injury. 

A review of the submitted documentation fails to support the medical necessity of skilled physical therapy services. The documentation submitted indicates the patient has reached Maximum Therapeutic Benefit (MTB) with the care plan. This is based on Policy # 84- Determination of Maximum Therapeutic Benefit. 

In summary, the health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. This is based on the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and the applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations. 

Novel approaches to ACL (Anterior Cruciate Ligament) rehabilitation develop continually. Nevertheless, several principles of rehabilitation have been shown consistently to be important for complete recovery. As an example, full range of motion, especially in knee extension, should be promoted immediately following ACL reconstruction. The inability to regain normal knee motion is associated with an increased risk of osteoarthritis (OA). 

Closed kinetic chain exercises to strengthen the hamstring and quadriceps muscles are effective for initial rehabilitation. Closed kinetic chain exercises require that both feet be planted and remain in a fixed position throughout the exercise (eg, squat). During open kinetic chain exercises the feet are not planted and change position. 

Controversy continues about the role of open kinetic chain (ie, open chain) exercises in ACL rehabilitation. Based upon limited evidence, we believe that strenuous open chain exercises may be added to the rehabilitation program no sooner than six weeks following surgery. However, specific open chain exercises that do not stress the knee or surgical graft may be used immediately following surgery. 

Exercises to enhance balance, proprioception, and core strength should be incorporated into postoperative rehabilitation, as should training to improve sport-specific biomechanics. The hamstrings are the primary muscle group that supports the ACL and thus hamstring strength is a critical aspect of rehabilitation. Patients who opt for nonoperative management also benefit from all the exercises described and should participate in a comprehensive rehabilitation program following injury. 

Motivated patients wishing to perform rehabilitation independently must be given clear instructions explaining how to perform the exercises correctly and should demonstrate proper technique to a knowledgeable clinician before beginning. Different muscle groups manifest relatively greater weakness postoperatively depending upon the site of the autograft. Specific rehabilitation protocols based on the autograft site have been developed. 

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

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