Is physical therapy, including therapeutic exercises, manual therapy, and re-evaluation of the plan of care, medically necessary for a patient with a diagnosis of M25.552 (pain in the left hip) and is this treatment experimental?

Medical Necessity Determination for Physical Therapy in Left Hip Pain

The requested physical therapy services (CPT 97110,97140,97164) for 8 visits over 4 weeks are medically necessary and NOT experimental for this patient with left hip pain (M25.552) following traumatic injury, given documented functional deficits, objective impairments, and demonstrated progress during initial therapy. 1

Rationale for Medical Necessity

Exercise Therapy (CPT 97110) is Strongly Indicated

• Exercise therapy is the cornerstone of conservative management for hip pain and is strongly recommended by multiple high-quality guidelines. 1
• The 2022 CDC Clinical Practice Guideline explicitly states that nonpharmacologic therapies, particularly exercise therapy, should be maximized for chronic pain conditions before considering other interventions. 1
• High-quality evidence demonstrates that exercise therapy for hip conditions reduces pain and improves function immediately after treatment with sustained improvements for at least 2-6 months. 1
• The American College of Rheumatology 2019 guidelines strongly recommend exercise as a preferred first-line treatment for hip pain and osteoarthritis. 1

Patient-Specific Justification

This patient demonstrates clear medical necessity based on documented impairments:

• Functional deficits: Difficulty with pivoting, stairs, sitting, kneeling, floor transfers—all activities of daily living requiring therapeutic intervention. 1
• Objective impairments: Moderate deficits in hip ROM and strength compared to contralateral side, weakness during closed kinetic chain exercises requiring therapist assistance (documented pg 15). 1
• Documented progress: Patient reports 55% improvement and demonstrates achievement of short-term goals 1 and 3, with long-term goals in progress (pg 16). 1
• Active participation: Clinical notes confirm patient understands therapy topics and actively participates in treatment sessions (pg 15). 1

Manual Therapy (CPT 97140) Justification

Manual therapy is appropriate as an adjunct in this specific clinical context, despite mixed guideline recommendations:

• The ACR guidelines conditionally recommend against manual therapy added to exercise for hip OA when compared to exercise alone. 1
• However, this patient's presentation differs from typical OA: traumatic injury (jetski accident 7/8/25), post-surgical status from open wound, acute-on-chronic pain pattern with sensitivity and numbness. 1
• Manual therapy is justified when rehabilitation is hindered by elevated symptom severity and irritability, which this patient demonstrates with disturbed sleep and pain limiting ADLs. 1
• The IHiPRN consensus for hip-related pain in young to middle-aged active adults supports manual therapy as part of comprehensive physiotherapist-led treatment when tissue tolerance to load is impaired. 1

Re-evaluation (CPT 97164) is Standard of Care

• Re-evaluation at 4 weeks is medically necessary to assess progress toward goals, modify treatment parameters, and determine if continued therapy is warranted. 2
• Documentation shows ongoing moderate deficits requiring continued intervention despite initial progress. 1

Visit Frequency and Duration Justification

The requested 2 visits per week for 4 weeks (8 total visits) is reasonable and conservative:

• MCG criteria suggest 14 visits for M25.552, making the requested 8 visits well within evidence-based parameters. 1
• The patient has already received initial therapy with documented functional progress, meeting MCG criteria for extended therapy. 1
• Treatment goals are not yet met, patient is actively participating, and adherent to the plan of care—all required criteria for continuation. 1

This Treatment is NOT Experimental

All requested interventions are well-established, evidence-based treatments:

• Therapeutic exercises (97110) have Level 1 evidence supporting their use in hip pain. 1
• Manual therapy (97140) is a recognized physical therapy intervention with established CPT coding and clinical guidelines, though evidence for added benefit over exercise alone is limited in OA populations. 1
• Physical therapy re-evaluation (97164) is standard clinical practice. 2
• None of these interventions are considered investigational or experimental by any major medical organization. 1

Critical Clinical Considerations

Key factors supporting medical necessity in this case:

• Traumatic etiology: This is NOT simple degenerative hip OA but rather post-traumatic hip pain with surgical intervention, which has different recovery trajectories. 1
• Age and activity level: Young to middle-aged active adult with hip-related pain—the exact population for whom physiotherapist-led rehabilitation is most strongly recommended. 1
• Absence of contraindications: No evidence of DVT, fracture, infection, new neurologic symptoms, or tissue rupture that would preclude therapy. 1
• Functional impairment: Documented inability to perform ADLs and IADLs with objective weakness requiring assistance. 1

Common pitfall to avoid: Do not conflate this traumatic hip injury case with degenerative hip OA studies that show limited benefit of manual therapy over exercise alone. The ACR guidelines specifically address OA populations, not post-traumatic injuries in active adults. 1

Recommendation

APPROVE the requested physical therapy services as medically necessary. The patient meets all MCG criteria for extended therapy, demonstrates objective impairments requiring skilled intervention, shows documented progress, and is actively participating in care. The requested 8 visits is conservative compared to the 14-visit benchmark for this diagnosis code. These are established, non-experimental interventions supported by high-quality clinical practice guidelines. 1