Issued and entered November 27, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On May 20, 2002, XXXXX (Petitioner) filed a request for an external review with the Commissioner of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act (PRIRA), MCL 550.1901, et seq. After a review of the material submitted, the Commissioner accepted the request.

A determination on medical issues was required. The Commissioner assigned the case to National Medical Reviews (NMR), an independent review organization (IRO). The Commissioner directed the IRO to obtain the opinion and recommendation of a medical expert.
The IRO completed its review on June 17, 2002, and sent it to the Office of Financial and Insurance Services (OFIS). A copy of the report is attached.

II
FACTUAL BACKGROUND

On May 9, 2001, Petitioner had surgery on her right knee to repair a torn anterior cruciate ligament (ACL) with medial meniscal repair. After surgery, Petitioner began physical therapy. Petitioner’s postoperative course was complicated by arthrofibrosis. On November 2, 2001, Petitioner underwent an arthroscopy with joint debridement and lateral release. Following this procedures, Petitioner was prescribed additional physical therapy.

Aetna Life Insurance Company (Aetna) denied coverage of the physical therapy following the November 2, 2001, surgery alleging the 20-visit physical therapy benefit per condition had been exhausted after Petitioner’s knee injury of April 17, 2001.

III
ISSUE

Whether Aetna properly denied Petitioner coverage for physical therapy after her November 2, 2001 surgery?

IV
ANALYSIS

Petitioner’s Argument

Petitioner states on May 9, 2001, she had surgery on her right knee to repair a torn ACL and medial meniscus. Following surgery, she began physical therapy. During her recovery, she experienced a complication of arthrofibrosis of the knee joint. On November 2, 2001, Petitioner underwent arthroscopy surgery with joint debridement and lateral release to her right knee. Petitioner’s physician informed Petitioner that both her ACL and medical meniscus were intact from the previous surgery.

After the second surgery, Petitioner’s physician prescribed additional physical therapy. Aetna denied Petitioner coverage for this additional physical therapy because her 20-visit physical therapy benefit had been exhausted by her April 17, 2001 knee injury. On February 26, 2002, Petitioner’s physician submitted documentation to Aetna describing the November 2, 2001, surgery as a separate procedure from the surgery performed on May 9, 2001. Petitioner’s physical therapist provided additional supporting documentation.

Petitioner argues the 20-visit physical therapy benefit per condition [emphasis added] should not be applied to the therapy received between November 2, 2001, and January 31, 2002, since this therapy was for a new condition [emphasis added].

Aetna Life Insurance Company Argument

On May 2, 2002, Aetna, through its third party administrator, Chickering Claims Administrators (Chickering), issued its final adverse determination. Chickering stated:

The XXXXXXXXXXXXXXXXXXXXXXXX Health Insurance Plan provides a 20-visit physical therapy benefit per condition. Please refer to page 22 of the 2000-2001 XXXXXXX plan brochure for information concerning the limited physical therapy benefits. Since the 20-visit limit has previously been paid relating to your knee injury of 4/17/01, no further benefits are available.

Aetna claims that Petitioner exhausted the 20-visit physical therapy benefit per condition and therefore their denial of additional benefits is consistent with Petitioner’s policy limitations.

Independent Review Organization (IRO) Recommendation

The IRO review was performed by a physician who is board certified in orthopedic surgery. The IRO report correctly noted the central issue was whether the physical therapy prescribed after the November 2, 2001, surgery was for a different condition.

The IRO reported the arthofibrosis was a second diagnosis. The IRO found this condition required aggressive operative management and physical modalities. The IRO concluded this condition was a completely different diagnosis from the May 9, 2001, diagnosis of anterior cruciate ligament with medial meniscal repair. Based on this finding, the IRO recommended the physical therapy prescribed after the November 2, 2001, surgery should be covered by Petitioner’s health plan.

Commissioner’s Review

The Commissioner concurs with the IRO recommendation, which found the physical therapy treatment performed after the November 2, 2001, surgery was for a new condition. The Commissioner therefore, concludes Aetna should provide physical therapy benefits, in accordance with the Certificate of Insurance (20-visits per condition) for Petitioner’s physical therapy treatment from November 2, 2001, through January 31, 2002.

V
ORDER

The Commissioner reverses the final adverse determination of Aetna Life Insurance Company in this matter. Aetna is required to approve and pay for Petitioner’s physical therapy treatment from November 2, 2001, through January 31, 2002, according to the terms of the policy. Aetna shall pay for such services within sixty days of the date of this Order and shall provide Petitioner and the OFIS proof of payment within fourteen days of payment. To seek enforcement of this Order, Petitioner must report any complaint regarding payment to the Office of Financial and Insurance Services, Health Plans Division, toll free at 1-877-999-6442.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.