Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy at a facility that provides weight training, has machines that test joint strength, and has an AlterG Anti-Gravity Treadmill. The current medical literature related to rehabilitation after anterior cruciate ligament (ACL) reconstruction supports early weight bearing, early range of motion exercise, and closed kinetic chain activities. 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 three postoperative months. Rehabilitation following ACL reconstruction can require be prolonged. However, the entire 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 patients involved in recreational sports. 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 (Yabroudi and Irrgang). Assessment and treatment of the injured knee, as well as the addressing of potentially disadvantageous compensatory biomechanics is appropriate for a comprehensive rehabilitation program following ACL repair. Overall, a period of supervised formal therapy following meniscal repair is generally warranted to initiate the program, followed by a transition to self-directed exercises when appropriate. Rehabilitation following ankle sprains generally involves a structured exercise approach to include strengthening and balance work, but optimal regimens including setting, dose and duration have not been established. While exercise therapy and interventions such as bracing are typically recommended for recovery following an acute or recurrent ankle sprain, the need for formal therapy services, including ultrasound therapy and manual therapy, have not been established in the medical literature The records provided for review document that this patient underwent right knee ACL reconstruction and treatment of a meniscus injury in November 2019. By February 2020, he had recovered functional range of motion at the knee. He was exercising on his own and progressing. By late May 2020, he was able to play soccer. There have been no indications of persistent, significant impairments related to the right knee since that time. The patient sprained his left ankle in late May 2020, but there are there are no indications that he has any persistent limitations at the left ankle that would impede his performance of his basic mobility-related activities of daily living. Although he may continue to have some symptoms related to his participation in higher level sports activities, no marginal benefit of formal therapy would be expected over a compliantly followed independent program. There are no indications of persisting impairments that would preclude a full transition to an independent exercise and modality program. Given these findings, the requested physical therapy at a facility that provides weight training, has machines that test joint strength, and has an AlterG Anti-Gravity Treadmill 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.