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202108-140280

2021

Healthfirst Inc.

Medicaid

Orthopedic/ Musculoskeletal

Physical Therapy

Medical necessity

Upheld

Case Summary

Diagnosis: Chronic low back pain
Treatment: Additional Physical Therapy Visits
The insurer denied the Additional Physical Therapy Visits
The denial is upheld.

The patient is a female. She has a history of chronic low back pain. The back pain
is associated with weakness and muscle spasms. This has been affecting her ADLs
(activities of daily living). She is into yoga and regular stretching exercises. She did
not achieve long-term relief from lumbar spinal injections, including epidural.

The patient started PT (physical therapy) earlier this year, for PT (physical
therapy) sessions until spring, with significant relief. Additional visits were
approved.

The patient's Oswestry low back pain rate was 38% disability, movement loss in
flexion and extension minimal, trunk muscle power average 4/5, all showing
improvement compared with previous report. However, she was still experiencing
pain with stiffness, lumbosacral hypo mobility with spasms, restricted function and
ADLs (activities of daily living), core weakness and difficulty with prolonged walking
or sitting. The request is for more additional physical therapy visits.

No, the Additional Physical Therapy Visits after the already-approved additional
sessions are not medically necessary.

The patient has shown adequate improvement from prior 20 PT (physical therapy)
sessions. Her Oswestry low back pain rating was 38% disability, movement loss in
flexion and extension minimal, trunk muscle power average 4/5, all showing
improvement compared with previous report, but still experiencing pain with
stiffness, lumbosacral hypo mobility with spasms, restricted function and ADLs
(activities of daily living), core weakness and difficulty with prolonged walking or
sitting.

The already-approved additional sessions were adequate towards transition to a
home exercise program for long term improvement. Therefore, continued PT
(physical therapy) sessions are not medically necessary.

As noted above, the continued Physical therapy after the already-approved
additional sessions is not medically necessary. The patient has shown adequate
improvement from the prior PT (physical therapy) sessions. Further PT (physical
therapy) sessions beyond the approved extra sessions were not medically
necessary, as further PT (physical therapy) session is not reasonably expected to
be health beneficial for the patient, and/or withholding it, in whole or in part, is not
reasonably expected to affect the patient's health adversely.

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