Printing - FECA-PT2 - National Association of Letter Carriers

need for further treatment as detailed under paragraph 16e below. If the information is not
available in the treating physician's medical reports, the CE should request a narrative report from
the treating physician and send copies of this letter to the physical therapist administering the
treatment and to the claimant. A sample request letter is shown in Exhibit 6. Authorization for
additional treatment may not be granted until this information is received and reviewed.
e. To evaluate the need for additional therapy, the CE weighs the medical evidence using the
following criteria:
(1) The PT is directed to the accepted condition or to an accepted complication of this
injury or condition, including surgery;
(2) The specific modalities, procedures and/or tests and measures include some form of
active PT as evidenced by the use of any of the following CPT-4 procedure codes: 97110
through 97116 (therapeutic exercises); 97240 (pool therapy or Hubbard tank); 97241 (pool
therapy or Hubbard tank, each additional body area); and 97500 through 97541 (orthotics,
prosthetics and activities of daily living training); and
(3) A functional deficit exists and the additional therapy is expected to produce some
functional improvement. Pain alone does not constitute a functional deficit. To authorize
additional physical therapy for pain, the CE should ensure that the pain is associated with
measurable objective findings such as muscle spasm, atrophy and/or radiologic changes in
joints, muscles or bones, or that pain has placed measurable limitations upon the claimant's
physical activities.
f. If these tests are met, the CE may authorize additional physical therapy for the period
requested or 90 days, whichever is less. The newly authorized dates should be added to the Notes
section of the Case Management File as described in paragraph c above, but the initial
authorization should not be deleted or overwritten. The authorized dates should also be entered in
the Physical Therapy portion of the FECS Case Management File (option 34). Failure to do so may
result in denial of bills for PT services. Up to two periods of authorization may be entered. If
necessary, the ending dates may be extended where additional periods of PT are authorized. The
CE notifies the treating physician, claimant and physical therapy provider (if different from the
treating physician) of the approval, indicating the specific period and CPT-4 procedure codes that
are approved.
g. If a second opinion examination is required to establish the need for physical therapy, the
CE will refer the claimant to a specialist conversant with physical therapy issues, such as an
orthopedic surgeon, neurologist or physiatrist. Cases in which this action may be necessary
include those where:
(1) The medical evidence is not in keeping with the three criteria described in paragraph
16e above;
(2) The therapy is for the accepted condition, but this condition is not orthopedic or
neurologic in nature;
FECA-PT2 Printed: 06/08/2010 349