Physmed I:

1. Do you authorized treatment? If so how much, and what is the basis for your
rationale? (HIGHLIGHT DETERMINATION AND GUIDELINES TO USE AND WRITE
BRIEF REASON)
a. Request: Post-operative physical therapy x 12 sessions.
i. Claimant is status post lumbar fusion procedure 2 months prior
and has completed 24 sessions of physical therapy to date. The
claimant has progressed with therapy with reduced pain scores
and improved range of motion measures. The claimant
continues to be off work.
CA jurisdiction: (HIGHLIGHT DETERMINATION AND GUIDELINES
ANSWER: Certification/Partial certification of _10_ visits /Noncertification
Guidelines: ACOEM revised/unrevised/CP MTUS/ ODG/ other
Postsurgical MTUS - Low Back - 724.0/ 722.7

Rationale: Guidelines allow for a maximum of 34 visits over 16

weeks post fusion surgery. There is evidence of subjective and
objective improvement. The claimant is still in the post-op
treatment period. The medical necessity of the request is
established.
Ohio state jurisdiction:
ANSWER: Certification/Partial certification of _10_ visits / Noncertification
Guidelines: ACOEM revised/unrevised/CP MTUS/ ODG/ other
Rationale: Ohio guidelines do not address this request. ODG-TWC
allows for 34 visits over 16 weeks post fusion. The claimant
shows evidence of improvement of pain and functional limitations.
The claimant is still in the post-op treatment period. The medical
necessity of the request is established.
Both these two cases could actually be full cert since the difference is
only of two visits, Im just sticking to the maximum allowed by the
guidelines though.
b. Request: Post-operative physical therapy x 12 sessions
i. Claimant is status post meniscectomy 8 month prior and has
completed 12 sessions to date. The claimant has progressed
with therapy with reduced pain scores and improved range of
motion measures. The claimant continues to be off work and
current range of motion is 10-90 degrees.
CA Jurisdiction
ANSWER: Certification/Partial certification of _______ visits / Noncertification

Guidelines: ACOEM revised/unrevised/CP MTUS/ ODG/ other

Postsurgical MTUS - Knee - 836/.0/.1/.2/.3/.5

Rationale: The claimant is 8 months from surgery and is not under

the post-operative treatment period any more. There is limited
indication of extenuating circumstances that might prevent the
claimant from addressing residual complains with home exercise
therapy
OK jurisdiction
ANSWER: Certification/Partial certification of _______ visits / Noncertification
Guidelines: ACOEM revised/unrevised/CP MTUS/ ODG/ other
Rationale: OK guidelines do not address this request. ODG-TWC
allows for a maximum of 12 visits over 12 weeks for postoperatory physical therapy treatment. There is limited indication
of extenuating circumstances that might prevent the claimant
from addressing residual complains with home exercise therapy.
c. Request for 12 sessions of Acupuncture with John Smith, Acu
i. Claimant has a date of injury of 3 years prior and has received
epidural steroidal injection, PT and chiro care in the past. The
claimant has continued pain complaints and has difficulty
reaching overhead and tolerating driving.
CA Jurisdiction:
ANSWER: Certification/Partial certification of _6_ visits / Noncertification
Guidelines: ACOEM revised/unrevised/CP MTUS/ ODG/ other
Acupuncture MTUS - All - Acupuncture

Rationale: CA MTUS states that Acupuncture is used as an option,

with a time to produce functional improvement being from 3 to 6
visits. The claimant has failed prior treatment and presents
ongoing pain and limitations. A trial of acupuncture is appropriate
to address current complaints.
2. What evidence and rationale should be utilized for Ortho Stim 4 unit?
Chronic Pain MTUS - DME-Modality - Neuromuscular Electrical Stimulation (NMES
Devices)
Chronic Pain MTUS - DME-Modality - TENS, Chronic Pain

ODG-TWC Pain Procedure Summary last updated 01/19/2015 states that

neuromuscular electrical stimulation (NMES devices) are not recommended.
ODG-TWC Pain Procedure Summary last updated 01/19/2015 states that
transcutaneous electrical nerve stimulation (TENS) is not recommended as a
primary treatment modality.

3. Name
a.
b.
c.

3 risk factors that would necessitate use of a bone growth stimulator.

One or more previous failed spinal fusion(s)
Grade III or worse spondylolisthesis
Fusion to be performed at more than one level