
202004-127202
2020
Fidelis Care New York
Medicaid
Orthopedic/ Musculoskeletal
Physical Therapy
Medical necessity
Upheld
Case Summary
Diagnosis: Musculoskeletal Pain
Treatment: 3 Visits of Physical Therapy
The insurer denied 3 visits of physical therapy.
The denial was upheld.
This is a female patient with complaints of musculoskeletal (MSK) pain; including but not limited to neck, back and ankles. The patient has a past history of in the neck, back and ankles surgery. The patient was treated with physical therapy in the past. Physical therapy was recommend and administered.
The minimal physical therapy treatment notes made available for review are hand-written, poorly legible and provide insufficient objective clinical information to support the medical necessity for the dates of service under review. The clinical records do not establish the medical necessity of continuing a structured out-patient physical therapy treatment program. The therapy notes merely document the date of service and type of therapy. There are no pain ratings, quantitative assessments or documented response to treatment. The lack of documented quantitative functional improvement renders the treatment under review as not medically necessary.
The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The carrier's denial of coverage for the 3 visits of physical therapy visits should be upheld. The medical necessity is not substantiated.