I am not a fan of most of the inspirational maxims that are often found in calendars, on posters, and the like. Earlier this year, a staff member in the office in which I work took down a calendar because of the number of times I expressed my distaste for the March maxim on a calendar. The statement included the premise that inside every acorn is a tree. Factually, that is just not the case. According to one Web site the chance of an acorn becoming an oak tree is approximately 1 in 10 000.1 Currently, I have a magnet on my refrigerator that states, "Today is not 'the first day of your life.' It's Thursday." Of course, factually, the first day of the rest of your life is actually the date of your birth. When I was young, I remember that on the milk carton was the cartoon character named Archie advising readers "Don't do drugs." This caused me to wonder about the mentality of a person who would decide not to do drugs based on a fictional cartoon character. If, from these examples, you deduce that I prefer objective factual statements that are supported by well-documented evidence, then to you I say ... welcome to my world. However, some might offer that you might be entering a world that includes viewing the world with doubt, cynicism, nonopenness (or closed), disbelief, and nonalternative (conventional) views. And to that opinion I say, "What a wonderful world I live in."

If you visit the American Physical Therapy Association (APTA) Web site, you have been able to read all the buzz about a couple of phrases that are bringing about apprehension and fear. Recently there have been increased limitations imposed to the amount of physical therapy that will be allowed for patients enrolled in the Medicare program. If you have not read about the CAPS limit, then I strongly suggest you educate yourself by going to the APTA Web site. Another concept that is causing lost sleep is that of "medical necessity." The Medicare program is placing increased burden on medical practitioners (including physical therapists) to provide evidence that the interventions/treatments that are proposed for a patient/client are indeed medically necessary. However, one problem that is receiving quite a bit of attention is the question of how medical necessity can be determined and documented. Indeed, in 2010, the Institute of Medicine developed a survey for the public so that people and entities might provide input regarding what they considered to be essential health benefits. The APTA submitted the following answer to one of the questions.

How is medical necessity defined and then applied by insurers in coverage determinations? What are the advantages/disadvantages of current definitions and approaches?

Insurers define medical necessity in nonuniform ways. Definitions of "medical necessity" point to accepted standards of good health care practices and then can further define the term as being curative or rehabilitative, or "clinically appropriate." Definitions additionally stipulate that treatment cannot be solely for the patient's convenience.2

When I read that a definition can be nonuniform, it brings a bit of discomfort to me. It reminds me of a recent political cartoon that I saw on a Web site. It had the caption "What happens in Vagueness, Stays in Vagueness."3

So, in my quest for a more concrete, objective, measurable definition, I went a'Googling. I found this definition from the American Medical Association.

The AMA defines medical necessity as: Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site, and duration; and (c) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other health care provider.4

The "prudent physician" standard of medical necessity ensures that physicians are able to use their expertise and exercise discretion, consistent with good medical care, in determining the medical necessity for care to be provided for each individual patient.

In a letter to the Secretary of the US Department of Health and Human Services, Kathleen Sebelius, that was dated January 31, 2012, R. Scott Ward, the President of the APTA, included the following text.

CMS Ruling 95-1 provides guidance of what criteria and methods should be used to determine medical necessity in determining the existence of "acceptable standards of practice" for Medicare contractors, within the local medical community. The following criteria should be considered: reliance on published medical literature, a consensus of expert medical opinion, and consultations with their medical staff, medical associations, including local medical societies, and other health experts. "Published medical literature" refers generally to scientific data or research studies that have been published in peer-reviewed medical journals or other specialty journals that are well recognized by the medical profession, such as the New England Journal of Medicine and the Journal of the American Medical Association. A consensus of expert medical opinion might include recommendations that are derived from technology assessment processes conducted by organizations such as the Blue Cross and Blue Shield Association or the American College of Physicians, or findings published by the Institute of Medicine.5

To satisfy my need for clarity, I have placed the criteria for medical necessity included in the statements above in bullet point format.

* Accepted standards of good health care practices

* Curative or rehabilitative

* Not solely for the patient's convenience

* Clinically appropriate in terms of type, frequency, extent, site, and duration

* Reliance on published medical literature from peer-reviewed medical journals

One problem that remains is that of determining the type, frequency, extent, site, and duration of the care that should be provided in an episode of physical therapy care that will result in measurable improvement in the functioning of your patient. I think that a justification letter to the Medicare reviewer that might state something like "I have been doing this treatment for 5-10+ years that I learned from a non-evidence-based continuing education course and my patients all seemed to improve within 6 to 20 visits" might not result in monies being transferred into your, or your employer's, bank account. Those days are gone. We must do better than that. I offer that the Latin phrase Verba Movent, Exempla Trahunt would guide us to more successful reviews. The phrase is interpreted as "Words move people, examples draw/compel them."6 My interpretation is that while what we say we do as physical therapists is appropriate as descriptive or explanatory statements, we must be always prepared to justify our plans of care with evidence from peer-reviewed research to those who are paying for our expertise and services. We must

* spend time reading the literature,

* search and use statistically proven valid and reliable outcome measures,

* forgo those treatments that have no well-researched evidence, and

* not attend continuing education courses to learn techniques that have not been tested with well-designed research.

Finally, my Googling did provide some instruction about how to increase the chance that an acorn will grow into an oak tree. Because I have not tested the instruction by trying to grow my own oak tree, I will not provide a Web site-I cannot vouch for the validity or reliability of the technique. I must do the research before I provide advice.

This issue of JWHPT does provide peer-reviewed research that will, I hope, influence the practice of women's health physical therapists. Dr Glenn Irion and his colleagues describe the current trends of interventions commonly provided for high-risk pregnancies. Drs Zellers, Chiarello, and Sage-King report on their examination of inter-recti distance in cadavers. Dr Trembeck-Ball and her coresearchers discuss the results of her research on the topic of young women and their self-efficacy for performing pelvic floor exercises. Drs Stacey Lillios and Jodi Young provide a review of the literature for the effects of core and lower extremity strengthening on pregnancy-related pain, and Dr Lowe and her colleagues report on the result of their survey of women's health specialists regarding their practice in the treatment of diastasis recti abdominis.

Now I am going to go out and collect the leaves from the oak tree in front of my house. I'll leave the acorns for the squirrels.

Nancy C. Donovan, PhD, PT

Editor-in-Chief

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