Appeal type: Medical Necessity
Decision: Overturned

The parent of an enrollee has requested authorization and coverage for a treatment plan which includes: 1) open reduction of the left knee with a ligament reconstruction and Judet quadricepsplasty; 2) open reduction of the right hip with insertion of a suture tether to hold the joint in place while it heals; 3) bilateral serial casting of the feet; 4) post-surgical hospital admission; and 5) post-surgical physical therapy.Regarding open reduction of the left knee with a ligament reconstruction and Judet quadricepsplasty, the patient presents with arthrogryposis and possible Larsons syndrome with congenital left knee dislocation that has caused a knee extension contracture. She has been treated conservatively with serial casting and physical therapy with persistent pain and inability to bear weight. Clinical findings have documented left knee range of motion as 0-60 degrees. Current evidence based medical literature supports this surgical intervention in this patients unique clinical scenario. Regarding open reduction of the right hip with insertion of a suture tether, the patient presents with arthrogryposis and possible Larsons syndrome with congenital right hip dislocation. X-rays of the hips show evidence of a teratologic right hip dislocation with moderate acetabular dysplasia. The patient has failed conservative treatment management with extensive physical therapy. Current evidence based medical literature supports this surgical intervention in this patients unique clinical scenario. Regarding bilateral serial casting of the feet, it has been recommended that the patients feet be serially casted again soon to prevent any regression. Current evidence based medical literature supports another round of serial casting in association with the surgical correction of other orthopedic lower extremity deformities to prevent any regression and maximize functional outcome. Regarding post-surgical hospital admission, the patient is indicated for staged open reduction of the left knee with a ligament reconstruction and Judet quadricepsplasty and right hip open reduction with insertion of a suture tether, as well as serial casting for her bilateral clubfoot deformity. The proposed treatment plan indicates that the patient would be admitted to the hospital for 2-3 nights after surgery. Regarding post-surgical physical therapy, the provider has indicated that physical therapy would be required in his facility for approximately 6 to 8 weeks after surgery. The proposed physical therapy treatment will be provided by the team of therapists working with the pediatric orthopedic specialist in a multidisciplinary approach. Evidence based medical literature indicates that rehabilitation is required in this patients clinical scenario and should be carried out by a team of specialists familiar with all aspects of arthrogryposis pathology and treatment modalities. Therefore, under the present circumstances, the requested post-surgical physical therapy at the pediatric orthopedic specialists facility is medically necessary.Given the above, the requested treatment plan is medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery 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.