Diagnosis: Compression of the median nerve in both hands

Treatment: Additional 5 visits of Physical Therapy Outpatient Services

The insurer denied coverage for the additional 5 visits of Physical Therapy Outpatient Services.

The denial is upheld.

This is a female patient with a history of compression of the median nerve in both hands; status post right carpal tunnel release. The patient had surgery performed for a right carpal tunnel release. She had a postoperative visit with the surgeon and was instructed to have 2-3 Physical Therapy sessions a week. The patient completed a total of 30 Physical Therapy sessions. Therapy sessions were interrupted for a few weeks.

The patient continues to complain of right hand (incision) pain, stiffness and weakness. She reportedly has difficulty performing activities of daily living. An additional 18 therapy sessions were recommended by the treating surgeon. However, currently under review are 5 additional visits of Physical Therapy outpatient services.

The earliest Physical Therapy note documents a pain level of 6/10.

Range of motion and strength measured:
Flexion: 0-58; 3-/5
Extension: 0-50; 3-/5
Pronation: 0-65; 3-/5
Supination: 0-65; 3-/5
Ulnar deviation (UD): 0-15; 3/5
Radial deviation (RD): 0-15; 3/5
Quick Dash rating was 38.49

The most recent note does not document any significant improvement. Pain level is rated 6-7 and Quick Dash ratings were no longer obtained.

Range of motion and strength are also unchanged:
Flexion: 0-58; 3-/5
Extension: 0-50; 3-/5
Pronation: 0-65; 3-/5
Supination: 0-65; 3-/5
UD: 0-15; 3/5
RD: 0-15; 3/5

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. The clinical records are insufficient to support the medical necessity of the requested 5 additional Physical Therapy visits.

From a physical medicine and rehabilitation/pain management perspective as well as within a reasonable degree of medical certainty, 5 additional visits of Physical Therapy outpatient services cannot be supported as medically necessary.

The carrier's denial of coverage for the additional 5 visits of Physical Therapy Outpatient Services is upheld. The medical necessity is not substantiated.