Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy. The peer-reviewed medical literature related to rehabilitation after ACL reconstruction supports early weight bearing and range of motion exercise, closed kinetic chain activities and early mobilization (Andrade, et al.; Eckenrode, et al.). The early rehabilitation process should be closely monitored to protect against graft failure and other complications, including infection and arthrofibrosis. As strength improves, open kinetic chain activities and more functionally advanced work can be introduced, although demanding physical activity is generally avoided during the first few to several post-operative months. Regaining higher level neuromuscular control of core muscles and optimizing other biomechanics factors are important to improve functional outcomes and mitigate risk of reinjury of the repaired ACL, as well as contralateral knee injury (Sepulveda, et al.). The entirety of the rehabilitation process following ACL reconstruction does not require a formal therapy setting. Home-based programs have been shown to result in similar long-term outcomes to more clinically supervised programs, particularly for recreational sports patients (Kruse, et al.; Papalia, et al.). Overall, a period of supervised formal therapy is warranted, followed by a transition to self-directed exercises when possible and appropriate. There is a lack of evidence-based consensus guidelines on rehabilitation protocols in the setting of concomitant ACL reconstruction and articular injury, despite the high frequency of this clinical scenario (Thrush, et al.). In the present case, the patient underwent right knee surgery in early May 2020, approximately two months following his injury, which included ACL reconstruction, medial meniscus repair and trochlear debridement. He was able to go camping and hiking for a couple of weeks. When he returned to his provider, he had relative atrophy in the right quadriceps, but there was full right knee range of motion with no documented extensor lag. His right knee ligaments were stable. There was no significant pain. There were no indications that he needed to gain more range of motion, strength, or stability in order for him to return to his activities of daily living. While the patient was still below his baseline level of function, there are no indications in the available documentation that the patient was performing any exercises in the therapy setting that he could not have performed independently or substituted with independent exercise. The records do not support an indication for continued physical therapy in lieu of instrument-assisted manual therapy or other passive therapy interventions. For these reasons, the requested physical therapy is not medically necessary for 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.