Diagnosis: Bilateral Knee Pain.
Treatment: Current procedural terminology (CPT) code 97110, PT (physical therapy) for 2 additional visits.

The insurer denied coverage for current procedural terminology (CPT) code 97110, PT for 2 additional visits.
The denial is upheld.

The patient has bilateral knee pain. Treatment included physical therapy. Under review is the medical necessity of CPT code 97110, physical therapy (PT) for 2 additional visits.
Based on the enclosed clinical information available for review, current procedural terminology (CPT) code 97110, physical therapy (PT) for 2 additional visits were not medically necessary. The physical therapy treatment notes provide insufficient objective clinical evidence to support the medical necessity of the services provided. The clinical records do not demonstrate the medical necessity of continuing a structured out-patient physical therapy treatment program from beyond the 3 physical therapy visits approved. This physician would also agree, the medical records do not demonstrate improvement can be expected within a reasonable time frame, services are needed to maintain, prevent, or slow a decline in condition, and the skill of a therapist is needed to manage, carry out, or set up a safe and effective treatment program. The patient should be functionally independent performing a home exercise program at the conclusion of the approved 3 physical therapy visits.

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based).

From a physical medicine and rehabilitation/pain management perspective as well as within a reasonable degree of medical certainty, current procedural terminology (CPT) code 97110, physical therapy (PT) for 2 additional visits was not medically necessary.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the current procedural terminology (CPT) code 97110, physical therapy (PT) for 2 additional visits is not substantiated. The insurer's denial is upheld.