Physical Therapy Reflection
A review of the records reveals the member to be an adult female with a birth date of 04/28/1948. The member has a diagnosis of status post left distal fibula fracture, tibial medial malleolus fracture requiring open reduction internal fixation (ORIF) in October 2014. The member’s treating provider, Jeffrey Fairley, DPT, recommended continued physical therapy services for the member from 02/27/2015 – 10/23/2015.
The carrier has denied continued coverage of physical therapy services from 02/27/2015 – 10/23/2015 as not medically necessary. There is a letter from the carrier to the member dated 01/14/2016 which states in part:
“The Committee upheld the denial based on the Definition of Medical Necessity per parts 1, 2, 4 and Exclusion …show more content…
The recommendation of WPS stated that the same outcome could have been accomplished with an “at home” program. I personally know this to be false. In addition to my regular physical therapy, I did maintain a daily “at home” program. I strongly believe both of these programs have been crucial to my recovery, especially the physical therapy sessions. I know the home exercise program alone would not have made the difference physical therapy has in my recovery. If I had not continued my PT visits, my physical limitations would have affected my work and …show more content…
The continued physical therapy services provided from 04/13/2015 – 10/23/2015 was not medically necessary for the treatment of this member’s condition.
The previous decision to deny coverage for the continued physical therapy services provided from 04/13/2015 – 10/23/2015 should be upheld
The carrier’s decision in denying coverage for the continued physical therapy services provided from 02/27/2015 – 04/12/2015 was not appropriate.
The continued physical therapy services provided from 02/27/2015 – 04/12/2015 was medically necessary for the treatment of this member’s condition.
The previous decision to deny coverage for the continued physical therapy services provided from 02/27/2015 – 04/12/2015 should overturned.
Findings:
The member is a 68 year-old who sustained a significant left ankle injury requiring an ORIF when she was struck by a
The carrier has denied continued coverage of physical therapy services from 02/27/2015 – 10/23/2015 as not medically necessary. There is a letter from the carrier to the member dated 01/14/2016 which states in part:
“The Committee upheld the denial based on the Definition of Medical Necessity per parts 1, 2, 4 and Exclusion …show more content…
The recommendation of WPS stated that the same outcome could have been accomplished with an “at home” program. I personally know this to be false. In addition to my regular physical therapy, I did maintain a daily “at home” program. I strongly believe both of these programs have been crucial to my recovery, especially the physical therapy sessions. I know the home exercise program alone would not have made the difference physical therapy has in my recovery. If I had not continued my PT visits, my physical limitations would have affected my work and …show more content…
The continued physical therapy services provided from 04/13/2015 – 10/23/2015 was not medically necessary for the treatment of this member’s condition.
The previous decision to deny coverage for the continued physical therapy services provided from 04/13/2015 – 10/23/2015 should be upheld
The carrier’s decision in denying coverage for the continued physical therapy services provided from 02/27/2015 – 04/12/2015 was not appropriate.
The continued physical therapy services provided from 02/27/2015 – 04/12/2015 was medically necessary for the treatment of this member’s condition.
The previous decision to deny coverage for the continued physical therapy services provided from 02/27/2015 – 04/12/2015 should overturned.
Findings:
The member is a 68 year-old who sustained a significant left ankle injury requiring an ORIF when she was struck by a