Diagnosis: Orthopedic/Musculoskeletal-Femur Fracture/Break.
Treatment: Physical Therapy (2 additional visits).

The plan denied physical therapy (2 additional visits) as not medically necessary. The reviewer has overturned in whole the health plan determination of medical necessity.

The patient has a history of bilateral knee degenerative joint disease (DJD) and left femur fracture status/post (s/p) open reduction internal fixation (ORIF). She was seen by her Orthopedic provider and was using a walker to ambulate. She noted her range of motion and condition is improving. She rated her pain as 6/10 with activity. On physical exam of the left lower extremity her incisions were well healed with minimal swelling. Her knee range of motion was 5-120 degrees with no tenderness to palpation and was neurovascularly intact. Range of motion was greater in the right knee than left. Sensation and motor was intact bilaterally. Assessment included knee pain and femur pain s/p left distal femur ORIF, weight bearing as tolerated, knee cortisone injection was discussed and performed. Physical therapy for knee range of motion and knee pain was prescribed. Left knee and femur X-rays were also obtained, which showed demineralization, mild to moderate tricompartmental osteoarthrosis, small osteochondroma and partially healed fracture of the distal femoral shaft s/p ORIF. The professional rehabilitation and physical therapy progress notes were also reviewed, and it was noted that she was compliant with physical therapy treatments and was slowly progressing towards her goals. She continued to have left leg and knee pain but was making slow improvement and was walking with a walker and having less pain. She continued to have weakness in the left leg muscles, and additional physical therapy was recommended.

The requested 2 additional visits of physical therapy are medically necessary for this patient, given the new report provided. The patient was seen by her orthopedic surgeon and continued to have pain and physical dysfunction. The patient had new X-rays which showed demineralization, mild to moderate tricompartmental osteoarthrosis, small osteochondroma and partially healed fracture of the distal femoral shaft s/p ORIF. She had a steroid injection to her left knee, and additional physical therapy was prescribed. The additional information from the X-rays justifies the need for additional physical therapy.