A review of the records reveals the member to be an adult female with a birth date of 04/28/1948. The member has a diagnosis of status post left distal fibula fracture, tibial medial malleolus fracture requiring open reduction internal fixation (ORIF) in October 2014. The member’s treating provider, Jeffrey Fairley, DPT, recommended continued physical therapy services for the member from 02/27/2015 – 10/23/2015.
The carrier has denied continued coverage of physical therapy services from 02/27/2015 – 10/23/2015 as not medically necessary. There is a letter from the carrier to the member dated 01/14/2016 which states in part:
“The Committee upheld the denial based on the Definition of Medical Necessity per parts 1, 2, 4 and Exclusion 8.
Your progress with increased function occurred over time, but objectively you made slow and minimal change overall with ROM (range of motion). The 2/18/15 progress note indicates that you were at a level not significantly different from your discharge from PT (physical therapy) on 10/23/15. There were improvements, but they were minimal and they do not support the 48 additional visits that were provided. Your treatment plan was the same on 2/23/15 as it was on 10/16/15 which shows that it was redundant.
Apollo guidelines for treatment of this condition are 24 visits over a three month period. You were treated over the course of 10 months which is beyond what is standard for this condition without significant objective and functional gains in an appropriate time frame. You could have been discharged to an independent home program as of 2/23/15 with similar outcome.”
There is a letter from the member received by WPS on 04/20/2016 that states in part:
“To summarize, I noted that the range of movement in my ankle and foot continued to improve throughout the additional PT sessions. The recommendation of WPS stated that the same outcome could have been accomplished with an “at home” program. I personally know this to be false. In addition to my regular physical therapy, I did maintain a daily “at home” program. I strongly believe both of these programs have been crucial to my recovery, especially the physical therapy sessions. I know the home exercise program alone would not have made the difference physical therapy has in my recovery. If I had not continued my PT visits, my physical limitations would have affected my work and lifestyle.”
Final External Review Decision:
The carrier’s decision in denying coverage for the continued physical therapy services provided from 04/13/2015 – 10/23/2015 was appropriate.
The continued physical therapy services provided from 04/13/2015 – 10/23/2015 was not medically necessary for the treatment of this member’s condition.
The previous decision to deny coverage for the continued physical therapy services provided from 04/13/2015 – 10/23/2015 should be upheld
The carrier’s decision in denying coverage for the continued physical therapy services provided from 02/27/2015 – 04/12/2015 was not appropriate.
The continued physical therapy services provided from 02/27/2015 – 04/12/2015 was medically necessary for the treatment of this member’s condition.
The previous decision to deny coverage for the continued physical therapy services provided from 02/27/2015 – 04/12/2015 should overturned.
Findings:
The member is a 68 year-old who sustained a significant left ankle injury requiring an ORIF when she was struck by a car.
As of 02/24/2015, she had attended 34 treatments sessions and was steadily improving. She had left foot and ankle stiffness with diminishing pain. She was showing improvements with range of motion but continued to have limited ankle dorsiflexion. She had ankle dorsiflexion to 5 degrees with inversion of 10 degrees, eversion of 5 degrees, and plantar flexion of 45 degrees. Her complaints included decreased ankle range of motion and decreased balance; joint line tenderness, left knee pain andinability to perform her regular exercise activity. She was subsequently prescribed and fitted for a Dynasplint.
The member was receiving treatments after a significant ankle injury. As of 02/27/2015, a DynaSplint was being fitted consistent with concerns over developing arthrofibrosis. She required skilled oversight in its appropriate use. She had decreased ankle range of motion and balance.
As of 04/13/2015, the member was attending her 45th physical therapy treatment session. She was deemed compliant with use of the DynaSplint, which was helping her and she had demonstrated improvement with walking. She had been able to resume more of her normal work activities. At this point, compliance with a home exercise program would be expected and would not have required continued skilled physical therapy oversight.
A home exercise program could have been performed as often as needed/appropriate rather than during scheduled therapy visits and could include use of TheraBands and a Biomechanical Ankle Platform System (BAPS) board for strengthening and balance. This would have better met this member’s needs. Thus, skilled therapy was no longer medically necessary as of this date.
Therefore, the carrier’s decision in denying coverage for the continued physical therapy services provided from 04/13/2015 – 10/23/2015 was appropriate.
The continued physical therapy services provided from 04/13/2015 – 10/23/2015 was not medically necessary for the treatment of this member’s condition.
The previous decision to deny coverage for the continued physical therapy services provided from 04/13/2015 – 10/23/2015 should be upheld
The carrier’s decision in denying coverage for the continued physical therapy services provided from 02/27/2015 – 04/12/2015 was not appropriate.
The continued physical therapy services provided from 02/27/2015 – 04/12/2015 was medically necessary for the treatment of this member’s condition.
The previous decision to deny coverage for the continued physical therapy services provided from 02/27/2015 – 04/12/2015 should overturned.
