Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: a patient requested authorization and coverage for direct manipulation techniques during physical therapy. At issue in this case is whether the requested direct manipulation techniques during physical therapy are medically necessary to treat the enrollees medical condition.Ehlers Danlos hypermobility syndrome is characterized primarily by joint hypermobility, chronic widespread pains and poor health-related quality of life. Generalized hyperalgesia has been reported, possibly due to a sensitized central nervous system, implying underlying pain mechanisms similar to fibromyalgia.   Hypermobile Ehlers Danlos syndrome is properly diagnosed using the 2017 International criteria which requires simultaneous presence of three criteria: generalized joint hypermobility (e.g., using a standardized Beighton score); evidence of syndromic features, musculoskeletal complications and/or family history; and exclusion of alternative diagnoses.  Treatment approaches with the highest rated subjective benefits in pain relief in survey literature have included opioids, splints, massage, and heat, but the effectiveness of treatment is generally reported to be poor, and evidence-based recommendations are largely lacking. The records in this case indicate that the patient has had various chronic pain conditions and other symptoms. The records do not indicate that the patient meets criteria for Ehlers Danlos syndrome.  There is no generalized hypermobility. The Beighton score was below the cutoff for her age.  Moreover, her cervical and thoracic spine have been assessed to be hypomobile, rather than hypermobile.  There is no indication for direct manipulation techniques during physical therapy from a provider specializing or otherwise well versed in the treatment of persons with Ehlers Danlos syndrome in this case. Given the patients overall history to date, it is not reasonable to expect that the proposed treatment would provide any clinically significant improvement in her symptomatology, function or health.  Passive interventions, such as manual therapy on a long-term basis, provide no proven objective benefit in the setting of chronic pain syndromes such as the type that this patient has had.  There are otherwise no exercises that that patient would be performing that she could not perform independently.  The patient is able on her own to stretch, jog moderately, and play a physically demanding musical instrument.  Therefore, direct manipulation techniques during physical therapy are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.